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LECTITEES ON" FEYEE 



DELIVERED IN THE THEATRE OP THE MEATH HOSPITAL 
AND COUNTY OF DUBLIN INFIRMARY. 



£- 



BY 



WILLIAM STOKES, M.D., D.C.L. Oxox., F.E.S., 

REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF DUBLIN, 
PHYSICIAN TO THE QUEEN IN IRELAND. 



EDITED BY 

JOHjST WILLIAM MOOSE, M.D..F.KQ.C.P. 
i 

ASSISTANT PHYSICIAN TO THE CORK STREET FEVER HOSPITAL, 

EX-SCHOLAR AND DIPLOMATS IN STATE MEDICINE 

OF TRINITY COLLEGE, DUBLIN. 







3f- S3 / 



PHILADELPHIA: 

H E N E Y 0. LEA 

1876. 



C^5 







*»t. Qflace Lib. 



THE FOLLOWING PAGES 

§w Jttateti to 
HENRY WENTWORTH ACLAND, M.D., LL.D., F.R.S., 

REGIUS PROFESSOR OF MEDICINE IN THE UNIVERSITY OF OXFORD ; 
HONORARY PHYSICIAN TO H.R.H. THE PRINCE OF WALES. 

WHOSE ENLIGHTENED EFFORTS TO SHOW THE RELATIONS OF CURATIVE AND 

PREVENTIVE MEDICINE TO THE HIGHEST INTERESTS OF 

MAN HAVE EARNED FOR HIM THE GRATITUDE 

OF ALL HIS FELLOW-WORKERS. 



PEEFACB 



It seems fitting I should mention that the following Lectures, the 
delivery of which has been spread over a considerable period of time, 
were not given in any regular sequence, so as to form a continued or 
systematic course. On the contrary, most of them were delivered at 
irregular intervals, and all as extemporary discourses. In one remark- 
able instance, this has led to the repetition of a very peculiar case of 
internal abscess in convalescence from Fever with icterus. As stated 
in the text, I was at first inclined to regard the liver as the primary seat 
of the abscess ; but at page 149 I have given reasons for concluding 
that the lesion was originally in the spleen. Several years intervened 
between the delivery of the first, and that of the second, lecture in 
which the case is mentioned. 

The place in which I spoke should be remembered — namely, the 
theatre of a General Hospital, containing, indeed, separate fever wards, 
but also wards for the treatment of cases other than those of essential 
disease. And so, with the view of publication, it became necessary 
to employ a good deal of selection as to the subject-matter of each 
lecture. Some of them, so far back as the year 1854, were edited by 
my friend and former pupil Dr. Lyons, and appeared in the Medical 
Times and Gazette under the head of " Clinical Lectures on Fever." 

Since that time, I need not say, the study and the teaching of Fever 
have been continued in the Meath Hospital, with at least one impor- 
tant result — namely, the valuable and original work of my trusted 
friend and late colleague Dr. Hudson, a work worthy to follow that 
of Dr. Graves for its learning, judgment, and practical worth. 

It appeared to me that lectures addressed to successive classes of 
clinical students, and grounded on constantly renewed observations 
in the sick ward throughout many years, would have a value different 
in kind from, if not superior to, any exhaustive history of fever, 
especially as regards the various theories of the disease or the obser- 
vations made by others. 

I have ever believed that the great object of a clinical instructor 



VI PREFACE. 

is twofold — first, that he should teach rather by example than by 
precept; and, secondly, that he should act more as a fellow-student 
than as a master. In this way the members of his class, associated 
with him in investigation, will learn as much or more by his example 
as they would by his precepts. They will taste the pleasure of 
original work and the value of self-instruction, and perceive that their 
great object is less to be taught by another than, in following his 
steps, to learn to teach themselves. This shows the superiority of 
clinical over systematic teaching in medicine. The former admits of 
immediate demonstration; and, from the ever-varying combinations 
and characters of essential disease, no one lecture can, as it were, 
repeat another. 

But while his discourses must vary from time to time, according 
as they may deal with the infinitely varied complications of local 
secondary disease, or in relation to the " epidemic character" of the 
essential or general malady, the duty of the teacher should ever be to 
imbue the minds of his hearers with the state of his own convictions 
on the subject in general. Thus he will furnish them with a knowl- 
edge less of particulars or of theories than of those broad principles 
which in after-life will guide them in dealing with disease. 



In the following Lectures I have considered in some measure the 
question of the separate identity of typhus and typhoid fevers, but I 
have not entered into it as fully as the labours of other observers in 
various countries might have encouraged me to do. I have preferred 
to dwell on the great subject of the relation of the secondary affec- 
tions of fever to the essential malady, and in the light of that relation 
to discuss the question of treatment. 

No one can deny that a normal case of typhus will show striking 
differences from a normal example of typhoid ; yet that these differ- 
ences belong rather to species than to genera, and that the principles 
of treatment of the two affections are the same, must,, as it appears to 
me, be admitted. In fact, the study of the points of agreement between 
the two forms of Continued Fever under discussion will be more 
valuable than that of their differences. 

They are both essential affections, in which the local anatomical 
changes are secondary to, or resulting from, the fever. 

They are both subject, although in varying degrees and at different 
times, to the Law of Periodicity. 



PEEFACE. Vll 

The characters of the constitutional and local symptoms in both 
vary as to intensity, amount, seat, combination, period of appearance 
and of cessation, and effect upon the primary disease. 

In both, the local symptoms may be only functional, or more or 
less connected with anatomical change. 

In both, local change may interfere with the law of periodicity, or 
even be attended by cessation of the constitutional symptoms. This 
has been observed more frequently in typhus than in typhoid. 

In both, the action of the law of periodicity applies not only to the 
general condition, but also to the secondary affections. 

In both, the local or secondary malady may take on a consequent 
condition of reactive irritation, thus adding a symptomatic to the pri- 
mary fever. 

The essential and local characters of both vary with the "epidemic 
constitution" of the time being. 

The symptoms of local disturbance, which are reliable as a guide 
to diagnosis where essential disease does not exist, in a great measure 
lose their significance in the presence of both forms of Continued 
Fever. 

In both, any or all of the functions may be disturbed singly, col- 
lectively, or successively, with or without corresponding anatomical 
change. 

In both, deposits of tubercular matter may occur as a secondary 
local affection. 

Similar exciting causes seem occasionally capable of giving rise to 
either form of fever. 

In "relapse cases" — I do not mean cases of Relapsing Fever — the 
character of the second attack may differ widely from that of the 
first. Thus typhus may give place to typhoid, or vice versa. 

The petechial or the measly eruption of typhus may coexist with 
the rose-spots of typhoid. 

Both forms are contagious, although in different degrees. 

As I have said, the principles of treatment in both are the same. 



These Lectures do not pretend to give even a sketch of all that is 
known or believed to be known respecting Fever. Nothing will be 
found in them relating to histological .research, the ohemico-vital 
states of the fluids or organs, or the analysis of the laws of crisis. The 
wide questions of the correlation or convertibility of essential disease 
are barely touched upon. Some of the facts connected with the 



Vlll PREFACE. 

change of type of disease, especially as regards the local affections of 
essential maladies, are mentioned. I have also spoken of the short- 
comings of the numerical system in medicine, of which Professor 
Trousseau, in the introduction to his immortal work, 1 writes as 
follows : — 

"Si la statistique appliquee a la medecine n'elevait pas trop haut 
ses pretentions, si elle se considerait non comme la clef de voute de 
toute science, mais comme un procede' un peu moins imparfait que la 
plupart de ceux que Ton suivait jusqu'ici, je ne songerais qu'& la 
louer, qu'a la presenter a votre choix, parce que re'ellement je la crois 
utile ; mais elle fait tant de bruit pour de si pauvres re'sultats, qu'on 
ne peut, en conscience, l'aider & tromper la jeunesse par une sorte de 
charlatanisme d'exactitude et de verite." 

The difficulties attending the application of the numerical system 
are nowhere greater than in the study of essential fever, because of 
the ever-changing nature of the epidemic type of the disease and of 
its secondary local affections. 

I cannot close this Preface without expressing my deep sense of 
obligation to my distinguished colleague Dr. Arthur Wynne Foot for 
a valuable record of temperatures in Fever, collected for the most part 
under his personal supervision in the wards of the Meath Hospital 
during the last three years. 

' Clinique medicale de l'Hotel-Dieu de Paris, deuxieine edition, tome l er , Introduction, 
p. xliv. 



CONTENTS 



PAET I. 

ESSENTIAL FEVER AND ITS SECONDARY AFFECTIONS. 



LECTURE I. 

PAGE 

Introductory — Injurious influence on the student and practitioner of having 
studied surgical cases exclusively — Influence of timidity from want of intimacy 
■with bed-side treatment of fever — Erroneous views in relation to the frequency 
of inflammatory disease — Inflammation not the primary cause of many local 
though acute affections — Errors of Broussais — Abuse of the antiphlogistic 
treatment 1 

LECTURE II. 

Change of Practice as regards the treatment of fever — Change of type in disease 
from sthenic to asthenic — Views of Alison — Sir Robert Christison — The author's 
views — Evidence (1) from symptoms, (2) from appearances of blood drawn by 
venesection, (3) from pathological appearances of internal viscera, and of serous 
membranes, (4) from isolated sthenic cases, and (5) from influence of treat- 
ment — Signs of a return to sthenic forms of disease — Vital character of disease 10 

LECTURE III. 

Fever described, but not defined, as "a condition of existence without any known 
or necessary local anatomical change and subject to new laws, different from 
those of health" — Error committed by the school of Broussais — The " Law of 
Periodicity" — Danger to the fever patient due to the primary disease or to its 
secondary complications — Secondary affections of continued fevers more incon- 
stant than those of the exanthemata — Classification of diseases: (1) Diseases 
having an anatomical character; (2) neuroses, having no known anatomical 
character; (3) fevers, subject to the law of periodicity, causing secondary affec- 
tions, transmissible by contagion ......... 20 

LECTURE IV. 

Contaoion — Exclusive doctrines are to be deprecated — Endemic disease arises 
independently of contact — The numerical system of Louis fails in practical 
medicine — Evidence in favour of contagion from the Doctrine of Chances — In- 
vestigations of Dr. Whitley Stokes and the Bishop of Cloyne; with Dr. Paget's 
remarks thereon — Variation in the degree of contagiousness of acute essential 
diseases . . .27 

LECTURE V. 

Causes of Fever — Preventive and Curative Medicine contrasted — Risk of error In 
limiting the number of the causes of disease — The correlation and the convcrti- 
bility of disease two important questions, the answers to which are not as yet 
fully or satisfactorily determined 34 

Appendix A 40 



X CONTENTS. 

LECTURE VI. 

PAGE 

Varieties of Fever as observed (1) in different epidemics, (2) in the same epi- 
demic, and (3) in members of the same family, living under the same conditions 
— This last-named fact is corroborative of the doctrine of the essentialism of 
fever — Definition of the term epidemic character of fever — Outbreaks of 1818-19, 
1826-27, and 1847 contrasted — Typhus and typhoid or enteric fever appear to 
be but species of the same genus — Contagiousness of typhoid fever — Dr. Flint's 
memoir — Principles of treatment of fever of any type must be based on an ac- 
quaintance with the laiv of periodicity, to which the disease is subject . . 42 

LECTURE VII. 

Points of Resemblance in the various forms of fever a more practical subject for 
investigation than their distinctions — As regards the principles of prognosis, 
diagnosis, and management, the various forms of fever lose their separate and 
individual significance — Points of resemblance between typhus and typhoid — 
The famine fever in 1847 — Recapitulation 49 

LECTURE VIII. 

Division of Fevers into Essential and Symptomatic— No anatomical expression 
for the disease — Secondary affections of fever — These may, and do, frequently 
produce organic changes — The presence of essential disease invalidates the 
ordinary rules of diagnosis — Illustrations of the truth of this statement — Local, 
symptoms of fever are (1 ) functional or nervous; (2) anatomical, i. e., depending 
on special anatomical changes : (3) secondarily inflammatory, i. e., arising from 
reactive inflammation, itself due to the typhous infiltration of some part or 
organ of the body — Similar symptoms may arise from essentially opposite con- 
ditions in disease — Illustrations of the proposition that fever is capable of pro- 
ducing local symptoms ivithout organic change ....... 55 

LECTURE IX. 

Local Changes in Fever are symptomatic, subject to laiv of periodicity, and prob- 
ably depend on the presence of a specific typhous deposit — This deposit pos- 
sesses a vital, specific character — Illustrations of this statement — The principal 
pathological conditions in fever are (1) functional, (2) intercurrent and secondary 
irritations of (a) mucous membranes, (h) parenchymatous structures, (c) serous 
membranes, (3) secondary irritations associated with typhous deposits, (4) inde- 
pendent typhous deposits, (5) neactive inflammations due to these deposits, (6) 
softening of organs — Effect of locality in determining the seat of secondary 
affections of fever — Effect of social rank in the same direction — Prognosis un- 
favorable and treatment by stimulation so far contra-indicated in cases where 
nervous symptoms preponderate 64 

LECTURE X. 

Secondary Bronchial Affection of Fever — Pneumo-typhus of Rokitansky — 
Views of this author as to the anatomical expression of typhus and typhoid 
respectively — Description of the bronchial affection of fever; frequent absence 
of symptoms therein — Rales sonorous, mucous, or crepitating ; no increased 
Bonoriety — This affection is not ordinary "bronchitis" ; it comes on silently and 
subsides spontaneously— 'Argument from the effects of treatment by stimula- 
tion — Modes of termination of the affection ....... 72 

LECTURE XL 

Bronchial Affection of Fever, continued — Alternating secondary affections — Im- 
perfect convalescence due to reactive bronchitis — Cases resembling phthisis — 
Three forms of tubercular disease, as a sequela of fever, (1) coexisting tubercle, 
(2) acute consequent tubercle. (3) consequent softened tubercle — Diagnosis based on 
the want of accordance between physical signs and symptoms in suspected phthisis 
after fever — Expectoration of small calculi some mouths after bronchial typhus 
— Tubercular fever in the typhus epidemic of 1826-1827 — This fever may be 
contagious ............. 78 



CONTENTS. XI 

LECTURE XII. 

PA8E 

Secondary Pneumonic Complications of Fever — Secondary congestion or consolida- 
tion of lung — The term "typhoid pneumonia" is incorrect — "Acute asthenic 
pulmonary disease," or "typhoid pneumonia," appears under seven forms — 
" Aborted typhus" in connection with the occurrence of lung consolidation — 
Local disease may assume a sthenic type even in the presence of a general 
asthenic condition — Description of the secondary pulmonary affection of fever 
under its three principal forms — Differential diagnosis between this disease 
and acute primary pneumonia, based on both pathological and anatomical 
grounds .............. 89 

LECTURE XIII. 

Pneumonic Complications of Fever, continued — "Typhoid pneumonia," so called, 
is not dependent on a coexistent gastritis — Correct view is that both pulmo- 
nary and intestinal lesions spring from the one parent condition, that of fever 
— Physical signs of ordinary pneumonia are often found, but in an irregular 
succession, in the secondary pneumonic affection — Sign of tympanitic resonance 
in latter, first described by Dr. Hudson — Probable causes of the production of 
this percussion sound — The author's views — Dr. Lyons' views — Three explana- 
tions of the production of the sign — Frequent absence of crepitus redux in 
resolution of secondary typhous disease — When inflammatory affections do 
occur in fever, they are reactive or tertiary in their nature — Typhous affec- 
tion of the larynx — Rokitansky's "laryngo-typhus" . . . . .98 

LECTURE XIY. 

The Heart in Fever — The state of the pulse, especially in typhus, not always a 
reliable guide — Weakening of the heart may coexist with a full, bounding 
pulse — Slow pulse in convalescence is consequent on a typhous weakening of 
the heart — Rapid pulse in convalescence is of unfavourable import, pointing to 
(1) tuberculosis, or (2) secondary reactive inflammation of the mucous glands of 
the intestine, or (3) phlegmasia dolens — In such cases the local malady assumes 
the prominence hitherto presented by the essential disease — Illustrative case 
of hepatic (?) abscess in convalescence from the yellow fever in 1826-1827 — 
Intermittent fever at close of epidemic in 1827 — Frequency of phlegmasia 
dolens — Bleeding in cold stage, after Dr. Mackintosh — Failure of quinine in 
cases of simulative ague, arising from (1) phlegmasia dolens, (2) urinary dis- 
ease, and (3) the puerperal state ... 106 

LECTURE XY. 

The Heart in Fever, continued — Louis' conclusions, based on post-mortem observa- 
tions — Typhous softening of the heart during life first studied at the Meath 
Hospital in epidemic of 1837-39 — As regards state of the heart, fever cases 
fall into three categories: those accompanied by (1) no alteration in heart's 
action, except of rate; (2) weakness after a few days, consequent on depressed 
• vital power; (3) cardiac excitement — Neither a depressed nor an excited state 
of the heart in fever necessarily implies organic change — Dynamic condition of 
the heart a more important indication for treatment than presence or absence 
of any structural change — True carditis very rare in fever — Typhous weaken- 
ing predominates in left side of the heart — State of involuntary muscular fibre 
in acute essential disease is of great importance — Laenuec's theory as to typhous 
softening of heart erroneous, for there is no correspondence between the soft- 
ening of voluntary and involuntary muscular structures — Illustrations from 
yellow fever of 1820-27 — Exemption of heart from typhous affection is a 
ground for a favourable prognosis — Continued excitement of heart equally a 
ground for a bail prognosis — Excited heart with compressible pulse most 
unfavourable — Transfusion of blood under these circumstauces — Absence of 
red blood after death, the only noteworthy pathological appearance in this case 
— Blood-waste in fever to be met by administration of nourishment . . 114 



XU CONTENTS. 

LECTURE XVI. 

PAGE 

The Heart in Fever, continued — Depression of the heart, more marked in typhus 
than in typhoid — Signs of the change connected with (A) the impulse, (/>') 
the sounds — The phenomena attending depression are variable — Description of 
their development, generally from the fourth day. 

A. Impulse: — Possible sources of error in diagnosis: (1) constitutionally feeble 

impulse, (2) emphysema of lungs — Necessity for comparison of condition of 
heart from day to day — Peculiar modification of impulse in certain cases — 
Vermicular action — Effect of position on impulse of heart — Loss of impulse 
generally progressive, sometimes rapid — " Where differential diagnosis is diffi- 
cult or impossible it is often unnecessary as a guide to immediate practice" — 
Retrocession of the local malady is gradual. 

B. Sounds: — First phase of lesion: second sound becomes relatively, but not 

positively, augmented. Second phase; disappearance of first sound. Third 
phase: disappearance of both sounds (a condition of most unhopeful augury) 
— Foetal character of the sounds in some cases — Speculations as to failure of 
second sound — Loss of impulse and failure of sounds generally advance pari 
passu, but not invariably so — As failure of sounds begins at the left side, so in 
recovery the phenomena follow the inverse course ...... 121 

LECTURE XVII. 

The Heart in Fever, continued — Post-mortem appearances in extreme typhous soft- 
ening — This affection not followed by chronic disease of the heart — Periods of 
invasion and of retrocession — Diagnosis of actual softening depends on (1) the 
character of the fever, and (2) the presistence of physical signs of failure of 
the heart — Simultaneous lessening of both sounds (foetal heart) — Its bearing 
on the treatment by stimulants — Slowness of pulse in convalescence from 
typhous softening — Analogy to fatty degeneration of heart with slow pulse — 
In latter case the phenomenon, however, is constant — Occasional reversal of 
the order in which the signs of typhous softening show themselves — Prognosis 
more favourable with depressed than with excited heart — Former condition is 
more amenable to treatment — Report on an epidemic of typhus at Stockholm 
in 1841, by Professor Huss — Cardiac murmurs in fever, especially in advanced 
stages of typhoid and relapsing fever are generally basic and systolic functional 
in character, and occasionally accompanied by veuous murmurs in the neck — 
Difficulty of distinguishing the first and second sounds of the heart in certain 
cases of disease: (1) chronic bronchitis, with weak and irregular heart and 
congested liver: (2) late stages of some forms of fever — Example of the 
latter — Diagnosis drawn from a want of accordance in the symptoms . . .117 

LECTURE XVIII. 

Secondary Intestinal Complications of Fever — General and introductory remarks 
— A generic resemblance between the various forms of fever — Secondary abdo- 
minal complications are more frequently observed in typhoid fever, but do not 
exist as its necessary anatomical character — Dothinenteritis was largely pre- 
valent in the typhus epidemic of 1826-28 — Fever must be observed independ- 
ently in each epidemic and in every country — Typhoid fever almost without 
characteristics symptoms — Illustrative case ; extensive intestinal ulcerations 
found after death — Vital symptoms of intestinal complication: (1) thirst, (2) 
swelling of belly, (3) diarrhoea, (4) ileo-csecal tenderness, (5) increased action 
of abdominal aorta, (ti) rigidity of adbominal muscles — Three forms of abdo- 
minal swelling: (1) early and moderate tympany, (2) doughy condition, (3) 
slight ascites — Increased action of abdominal aorta — Case of, in perforation of 
the stomach— Analogous local arterial excitement in (1) whitlow, (2) rheuma- 
tism — Diagnosis from aneurism — Intestinal complications seem to interfere 
largely with action of the law of periodicity — Early elevation of local irrita- 
tion checks deposit, and so prevents future mischief — Hence relief of symptoms 
by early depletion as practised by Broussais, who misinterpreted the matter, 
and was led to look upon the general fever as but symptomatic of a local 
lesion 135 



CONTENTS. Xlll 

LECTURE XIX. 

PAGE 

Intestinal Complications of Fever, continued — They resemble all the other secon- 
dary affections of fever in their general characteristics and relations to the 
primary essential malady — More frequent in typhoid, but occurring in typhus 
also, as, for example, in the epidemic of 1826-27 — Pathological appearances 
observed in the intestinal tract in fever — Yet these appearances were not neces- 
sarily found after death even where severe abdominal symptoms existed in life 
— Eruption of rose spots in fever ....... . . 142 

LECTURE XX. 

Intestinal Complications of Fever, continued — Division into three categories, with 
reference to the vital symptoms: I. These symptoms are absent, although the 
silent disease may be great in amount ; II. Local symptoms are evident; III. 
Symptoms and pathological changes are both well marked — Further description 
of the epidemic of 1826-27 — Sudden access of intense abdominal pain, followed 
by icterus and gangrene — Fatality of this complication — Splenic(?) abscess oc- 
curring in the first case of recovery, and discharging through the lung — Resem- 
blance of this form of fever to the yellow fever of the tropics — Dr Lawrence's 
observations — Dr. Graves' observations 146 

LECTURE XXI. 

Intestinal Complications of Fever, continued — Organic changes — Perforation of 
intestine — Of common occurrence in 1826-29: (1) Generally rapidly followed 
by symptoms of peritonitis; (2) but may be unattended by local symptoms in 
progressive cases, or again may induce only limited peritonitis (adhesions) ; (3) 
Symptoms of perforation may be veiled by the coexistence of intense irritation 
in another cavity of the body — Illustrative case — Time of occurrence of perfora- 
tion as observed in six cases — Diagnosis of internal solutions of continuity is 
based on sudden development, without apparent exciting cause, of new, local, 
violent, and often rapidly fatal symptoms — Cases to which this rule of diag- 
nosis is applicable — In effusion into a serous sac the degree of resulting inflam- 
mation is determined chiefly by the quality of the effused fluid — Examples — 
Influence of an irruption of pus in producing serous inflammation contrasted 
with that of an irruption of blood — Physiological difference between pus cor- 
puscle and white-blood cell — The formation of conservative adhesions seems to be 
rarer in peritonitis than in pleuritis— Case of hepatic abscess in which adhe- 
sions occurred and recovery followed (diagnosis from abdominal aneurism) . 151 

LECTURE XXII. 

Secondary Nervous or Cerebro-Spinal Complications of Fever — When they 
predominate, prognosis is unfavourable — Of all secondary typhous affections 
they are least connected with organic change — Probable reason ; mucous mem- 
branes and skin undergo anatomical change more readily than serous mem- 
branes — Cerebral inflammation rarely observed in fever — Purpuric fever of 
1867 an exception — Absence of organic change in typhous cerebral derange- 
ment does not lessen its importance as regards prognosis and treatment — 
Inadmissibility of routine treatment, either antiphlogistic or by stimulation, in 
fever — Results obtained by Louis as to relation between head symptoms and 
pathological change in fever — Actual cercbritis, when it does occur in fever, is 
a tertiary phenomenon — Dr. Hudson's cases — Study of analogies is of impor- 
tance in essential diseases ; thus relief of headache in early stage of smallpox 
by leeching is analogous to good results of moderate depletion in early stages 
of some cases of fever — Further examples of the effect of lessening vascular 
supply in controlling development of smallpox eruption — Analogy in case of 
secondary affections of fever — Nervous symptoms arise from three conditions: 
(1 ) influence of fever-poison, (2) urtcmia, (3) specific secondary inflammation, 
probably erysipelatous in character . . . . . . . .159 



XIV CONTENTS. 

LECTURE XXIII. 

PAGE 

Nervous Complications of Fever, continued — Cerebrospinal fever — Phenomena of 
fever inconstant and variable, except, perhaps, the phenomenon of increased 
temperature — Type of fever also varies in different epidemics — Two examples: 
(1) yellow fever of 1826-27, (2) malignant purpuric, or cerebrospinal fever of 
1867 — Dr. E. W. Collins' report on latter — There exists a "constitutional ele- 
ment" in the disease, so that the cerebro-spinal arachnitis can hardly be held 
to be a primary, idiopathic affection — Evidences of essentiality from presence 
of other phenomena in connection with the skin, etc. — Reports to the Medical 
Society of the King and Queen's College of Physicians in Ireland on the epidemic 
of 1867 — Inconstancy and variability of the symptoms in the outbreak — Dr. 
H. Kennedy's views — Symptoms of the disease — Petechise — Early setting in of 
putrefaction — Retraction of head; sometimes persistent after disappearance 
of other local and general symptoms, and sometimes persistent after death — 
Recapitulation: Points to be considered in connection with epidemic of 1867: 
(1) yellow fever of 1826-27, (2) cerebro-spinal arachnitis of 1846 (Dr. Mayne), 
(3) coincidence of cases of malignant measles in 1867, and (4) hemorrhagic 
and purpuric smallpox in epidemic of 1871-72 ...... 165 

LECTURE XXIV. 

Nervous Complications of Fever, continued — Hysteria — Occurrence of hysteria, 
especially at an early stage, of unfavourable import — View that hysteria is 
always symptomatic of uterine excitement is quite erroneous — Nymphomania 
only a loeal and accidental manifestation — Hysteria is observed in males as 
well as in females in fever — Case of erotic symptoms in typhoid fever occur- 
ring in a young girl, reported by Dr. A. W. Foot — In early stage of fever hys- 
teria generally is the precursor of severe nervous symptoms — Its appearance 
may lead to serious complications later in the disease — Illustrative cases — 
Hysterical symptoms are sometimes connected with actual or organic disease, 
especially in acute affections — Dr. Cheyne's observation : Hysteria a ground for a 
good prognosis in every disease, fever alone excepted — Outbreak of hysteria, affect- 
ing the abdomen, in female fever ward of Meath Hospital — Anomalous symp- 
toms in advanced stages of fever often due to hysterical state — Case of typhous 
hysteria in the male followed by cerebritis 173 



PART II. 

TREATMENT OF FEVER. 



LECTURE XXV. 

Introductory Remarks— Principles on which the treatment of fever is to be based 
— True meaning of the word empiric. Historical retrospect — The Symptomolo- 
gical, the Anatomical, the Rational or Eclectic Schools — Essence of fever cannot 
be determined by pathological anatomy — Etiology of fever is indefinite . . 177 

LECTURE XXVI. 

No specific line of treatment — Respect to be had (1) to the essential disease, (2) to 
its local and secondary effects — Failure of specifics in early stage of fevers — 
Want of success in the endeavour to found a science of therapeutics on experi- 
mental physiology or pathology — Effects of the action of the law of periodicity 
wrongly attributed to the adoption of therapeutical measures — Sustenance by 
food and stimulants — Two sources of danger to the fever patient: (1) primary 
effects of the fever poison in causing depression, (2) supervention of secondary 
local disease — Views of Dr. Graves on the subject of giving food in fever . 185 



CONTENTS. XV 

LECTURE XXVII. 

PA8E 

Stimulants in Fever — Views as to the nutrient properties of stimulants are to be 
received with caution — Anticipatvie use of stimulants — Meaning of the term — 
Considerations to be taken into account in resolving upon this method of treat- 
ment : (1) prevailing epidemic character of the disease, (2) previous condition 
of the patient — " Sinking of vital power" — Illustrative case — Stimulation often 
unsuccessful in the intemperate, and in those whose brains are over-worked, 
(3) development of symptoms of severe typhus, (4) development of fever odour 
— Contrast between typhus and typhoid as regards period at which stimulation 
is called for — Condition of the heart, a guide — Physical signs of cardiac weaken- 
ing 193 

LECTURE XXVIII. 

Stimulants in Fever, continued — Signs in connection with the heart of the agree- 
ment of stimulants: (1) return of impulse, (2) return of first sound, (3) 
gradual fall in the rate of the pulse — In cases of "foetal heart" great boldness 
in stimulation is needed — No certain rules as to quantity of wine and whiskey 
or brandy required — Examples of free use of stimulants in malignant typhus — 
Case of Hardcastle (typhoid fever) — Eruption of vesicles as a secondary com- 
plication — Bed-sores ..... ...... 201 

LECTURE XXIX. 

Stimulants in Fever, continued — Case of Hardcastle, continued — Treatment by 
food and stimulants in extreme cases — Presence of cerebral symptoms to a 
great extent unfavourable to the exhibition of stimulants — Necessity for daily 
observation to the effects of the treatment in each case — Signs of disagreement 
of stimulants — Routine practice is in every instance to be deprecated — Falla- 
cies of the numerical system in therapeutics — History of routinism — Its results 
— Description of routinism in the treatment of fever ..... 212 

LECTURE XXX. 

Treatment of the Local Secondary Affections in Fever — Relative importance 
of these affections as regards prognosis — Bronchial Affection — Necessity for 
administration of stimulants and nourishment — Danger of exhibition of tartar 
emetic — Failure of emetics — Turpentine-punch — Dry-cupping, poulticing, blis- 
tering — Internal remedies: bark, ammonia, spirit of chloroform, turpentine — 
Acute Consolidation of the Lung — Its three forms — Treatment of the first 
form by dry-cupping, blisters, quinine, turpentine, and wine — Of the second 
form by local depletion simultaneously with the administration of wine — Of the 
third form, externally by iodine and blisters, internally by tonics and iodide of 
potassium 222 

LECTURE XXXI. 

Treatment of Intestinal Secondary Affections — Two chief indications: (1) alle- 
viation of symptoms, (2) modification of typhous deposition — Poulticing — Local 
depletion in early stage — Analogy in variolous eruption — Danger of alterative 
or purgative treatment at the outset of Continued Fever — Necessity for caution 
— Constipation — Diurrhmn — Poultices, demulcents, sedative astringents, injec- 
tions of flax-seed tea — Tympany — Turpentine injection — Diet in diarrhoea — 
Perforative peritonitis — Opium our sheet-anchor — Danger of the antiphlogistic 
method — Dr. Murchison on the treatment of this accident — Bran poultices and 
warm fomentations — Hemorrhage from the intestine iu fever — Not to be inter- 
fered with unless continued and excessive — Treatment by astringents, opium 
— Illustrative case .......... . 227 



XVI CONTENTS. 

LECTURE XXXII. 

PAGE 

Treatment of the Nervous Secondary Symptoms of Fever — Headache — Cold 
lotions, warm fomentations, moderate leeching, shaving the head, cold affusion, 
ice — Delirium — Treatment depends on (1) period of case, (2) presence of hyper- 
emia of the brain, or otherwise — Ice, leeches, shaving the head, cold affusion 
in active delirium — Nourishment and wine in passive or anaemic delirium — 
Sleeplessness — Moderate leeching, cold affusion, ice — Turpentine in constipa- 
tion and tympany — Catheterism in distended bladder — Sedatives — Opium, 
tartar emetic and opium, hyoscyamus, bromide of potassium, chloral, wine — 
Convulsions — Most formidable in fever — Uremic, due to (1) retention of urine : 
catheterism ; (2) suppression of urine : dry cupping and poulticing over kidueys, 
diluents, diuretics, aperient enemata, promotion of action of the skin . . 237 

LECTURE XXXIII. 

Phlegmasia Alba Dolens — The swelling is not always painful, or white in appear- 
ance — Symmetry of the affected limb not lost — Professor Trousseau's views as 
to the etiology of the affection — Phlegmasia (1) of puerperal women, (2) in 
scrofulous and (3) cancerous cachexise — Pulmonary embolism caused by phleg- 
masia — Case of phlegmasia after typhus fever — Treatment of the affection — 
General Conclusion 245 

Appendix B 253 

INDEX 257 



LECTURES ON FEVER. 



PART I. 

ESSENTIAL FEYER AND ITS SECONDARY AFFECTIONS. 



LECTURE I. 

Introductory — Injurious influence on the student and practitioner of having studied 
surgical cases exclusively— Influence of timidity from want of intimacy with bed- 
side treatment of fever — Erroneous views in relation to the frequency of inflamma- 
tory disease — Inflammation not the primary cause of many local though acute 
affections — Errors of Broussais — Abuse of the antiphlogistic treatment. 



Several of the hospitals io Dublin, considered as schools for 
clinical study, have the advantage of being essentially medico-chi- 
rurgical hospitals — that is to say, that in them the student, in con- 
nection with his surgical pursuits, may see and study most forms of 
the so-called medical diseases, which include not only the acute and 
chronic local diseases, but the various forms of essential affections, 
including continued fevers. 

I am anxious to draw the attention of the surgical student to the 
all-important subject of fever; for when we consider the enormous 
extent to which this fell disease, or group of diseases, prevails over 
the world, and also that it is in itself a special study, we cannot help 
believing that the student who has not dealt with fever, no matter 
how ably he may have been educated in surgery and in the history 
of visceral diseases, has but half learned his business. 

The importance of a practical knowledge of fever, as distinguished 
from that obtained from books or lectures, is not yet sufficiently 
impressed on the surgical student. If such a one possesses a reflect- 
ing mind, he will have abundant and bitter causes of regret at having 
neglected his hospital opportunities, whereby alone he can obtain that 
intimacy with the subject which will be his guide and safeguard in 
after-life. It is in the fever-wards alone that he can learn the price- 
less lesson that there is a large class of diseases, whose nature and 
property it is to get well of themselves, which require little or no 
1 



2 LECTURES ON FEVER. 

medication or daily interference. This lesson is not to be learned 
from purely surgical studies, one effect of which leads in medicine to 
the nimia diligentia, so common a fault in practice, so clear a sign that 
the medical mind has not been formed. He will see that what the 
patient requires is in many cases only time, and to be kept from 
sinking by proper support. He will come to learn how this great 
fact of the spontaneous cessation of disease bears on all therapeutical 
research in fever by showing him that he is not to confound the post 
hoc with the propter hoc. He will learn that there are few questions 
more difficult of determination than the effect of any special remedy, 
or even general mode of treatment in diseases which are under the 
law of periodicity; and thus he will be taught caution in drawing 
conclusions as to his own practice, while he will be charitable in re- 
flecting upon that of others. Take for example the case of rheumatic 
fevers. How long have physicians been seeking for a specific treat- 
ment? Venesection, blistering, mercury, opium, bark, alkalies, acids, 
have all had their advocates, whose statements are supported by 
genuine cases, and yet the question remains unsolved; would not the 
disease have subsided of itself as well, and as quickly, as under any 
specific treatment? And in case of recovery, may not this even have 
occurred notwithstanding the treatment ? 

I heard with great pleasure the report by my distinguished friend 
Dr. Sibson, read at the meeting of the British Association at New- 
castle-upon-Tyne, in which a long series of cases of rheumatic fever 
was detailed as having been successfully treated without any medicine 
beyond small doses of peppermint water — given, I presume, to satisfy 
the minds of the patients that something was being done for them 
beyond keeping them warm in bed till the disease subsided. 

It is not to be understood that Dr. Sibson does not recognize the 
frequency of local inflammation in rheumatic fever, and the necessity 
of meeting it in many cases. But his researches are directed to show 
the comparative uselessness of a specific treatment. 

I well remember the time when surgeons, who had been otherwise 
well educated, but had never in their student days seen or attended a 
case of typhus fever, objected to deal with such a case, and were of 
course, from apprehension of contagion, more or less ineffective when 
brought to perform any operation such as catheterism, and so on. 

All students who are looking to the public service, whether in the 
civil, military, or naval department, should be taught by those who 
assume their direction or instruction that they cannot tell when they 
may have to deal with fever even on a great scale, and that, as the 
principle of treatment of all fevers is the same, the study of the dis- 



GENERAL CONsI DERATIONS. 3 

ense at home will fit them to meet the yellow fever, the bilious 
remittent, the camp fever, the plague of the Levant, and the cholera 
of India. 1 

How few of our surgical students are aware of the fact shown by 
Sir Gilbert Blane that in the Peninsular War more men died of fever 
than from all other causes, including the sword. 

But, further, the student who confines himself to merely a surgical 
ward often enters on his profession unfitted by timidity to meet his 
foe. I have known several instances where surgeons in civil practice, 
though willing to do their duty, were always nervous on entering a 
fever ward. I do not say that such men were cowards in the ordinary 
sense of the word, or that the feeling of danger would make them 
shrink from discharging their duty; but there is a condition which 
may be described as physical fear, distinct from moral fear ; a condi- 
tion of susceptibility to contagion, which is doubtless lessened by 
intimacy with disease. I know of a gentleman who was called to 
inspect the body of the first victim of cholera in the earliest and great 
epidemic of 1832. The case occurred some miles from Dublin. 
During his return he had many of the symptoms which threaten an 
attack of cholera. He had the abdominal pains, the feeling of immi- 
nent death — "the cold meditation of death" of the old authors — cramps, 
and other symptoms. For two days these recurred. The epidemic 
shortly afterwards burst out with violence in the city, when, feeling 
that if this condition persisted he would be unable to do his duty, he 
entered a crowded temporary cholera hospital, where he remained 
for thirty-six hours in close attendance on the sick. During the first 
eighteen hours seven patients died, it may be said, in his arms. I 
need not say that all the yielding of the system he had shown rapidly 
disappeared. I know of another case, where a gentleman, now an 
eminent member of the profession, was cured of repeated attacks of 
cholerine by undertaking the office of house surgeon to a large cholera 
hospital, where, under the direction of the late Dr. Mackintosh, he 
had to conduct the treatment by venous injection in many cases. To 
mention a third instance, the case of Mr. West and his party is quoted 
by my father, Dr. Whitley Stokes, in his pamphlet on Contagion. 2 
During the expedition to Egypt under Sir Ralph Abercrombie Mr. 
West was ordered to take charge of a pest hospital at Rosetta in the 
beginning of May, 1801. In this house he was shut up for four 
months. His staff consisted of an assistant surgeon, an Italian ; an 
English soldier; and of Arab servants. " No one of the party took 

1 See Swan's Edition of Sydenham, page 75. 

- Observations on Contagion, 2d edit., Dnbliii. 1818. 



4 LECTURES ON FEVER. 

the disease, although Mr. West operated and dressed the buboes 
himself, and treated sores from anthraces so extensive that half a 
pound of flesh sometimes came off by sloughing; and although the 
servants washed the sheets, bedding, and bandages, rubbed the patients 
with mercurial ointment extensively, supported the faint, tied the 
delirious, and buried the dead. In short, they were exposed as fully 
as possible to contagion. At this time the plague was so severe at a 
village twenty-five miles from Eosetta that one-fourth part of a popu- 
lation of 400 died within a month. I have said that none of the 
party took the disease. Great attention was paid to cleanliness, and 
the house was a roomy building, situated on an elevated bank over 
the Nile and exposed to the northwest sea breeze. 

On this singular result Dr. Stokes remarks, "Mr. West's deep in- 
terest in the discharge of his duty and in the improvement of his 
profession must have contributed to turn his mind from the selfish 
melancholy contemplation of his personal risk, a risk which one of 
our best officers fairly compared to that of a hundred battles. Such 
has been the triumph of good sense, temperance, firmness, and in- 
dustry ; and Mr. West has earned a civic crown which some men will 
venture to compare with the laurels of the greatest conquerors." 

The surgical student who has not studied fever in the living sub- 
ject, and himself felt the responsibility of its management, is in this 
position : the doctrine of the universality — or of the extraordinary 
frequency, whichever you will — of inflammation has been impressed 
on his mind in every possible way, for the ordinary practice at the 
commencement of a course of surgery used to be to occupy the student 
for many weeks with the history of inflammation. Inflammation is 
thus placed in the foremost rank. It is the great thing to which his 
earliest attention is directed, and naturally it appears to him to be the 
key to all medical and surgical knowledge. It is still more impressed 
upon him by the kind of experience he gets during a considerable 
part of his studies. That experience is obtained in a surgical ward, 
and it is hence very natural that he should have exaggerated notions 
of the importance and frequency of one morbid process. Too often 
at the end of his course he finds that he has been taught only inflam- 
mation, he has seen little else than inflammation, and he believes in 
little else than inflammation. A great many students are educated 
in this way, and they go forth to the world ignorant of two facts in 
practical medicine and surgery, the importance of which cannot be 
overrated. The first is the existence of an enormous number of acute 
and dangerous diseases which are not inflammatory — of diseases, as I 
said before, which are acute, which are dangerous, and still further, 



GENERAL CONSIDERATIONS. 5 

which are febrile. The idea has never been impressed on their minds 
that there may be a local, acute, febrile, and most dangerous disease 
which is not only, to use the words of a recent author, not inflamma- 
tion, but something the very opposite of inflammation. When we 
consider that it is in the various forms of fever that these conditions 
are met with, and when we recollect the extent to which fever pre- 
vails over the world, we are justified in declaring that when we 
compare diseases in which inflammation is the primary condition with 
those in which it is not, the former fall immeasurably short of the 
latter in number and importance. 

The other great fact is that the student has not learned the error of 
exclusive antiphlogistic treatment in the management of ordinary 
primary inflammation. From not having had to deal with local dis- 
eases, which require not the lancet, not starvation, but rather tonics 
and wine, he has never become accustomed to, or familiar with, the 
latter remedies. He is timid in the use of these measures, and even 
in the ordinary primary diseases he follows too long the common rule 
of antiphlogistic treatment instead of changing in time to one of a 
tonic and stimulating nature. The erroneous application of the anti- 
phlogistic method arose subsequent to a change of doctrine from 
humoralism to solidism. 

In order to get a clearer notion of this matter, let us go a little 
back. Before pathological anatomy became a science it was held 
that a large number of diseases depended on the alterations of the 
fluids. But when anatomy was directed to the investigation of dis- 
ease medical opinion underwent a change, and solidism succeeded to 
humoralism. Disease was then an alteration of the solids, the living 
tissues of the body. Now, I wish to impress upon you that solidism, 
as was then understood, soon came to mean more than its original 
name would imply; and solidism plus the doctrine. of inflammation 
became the ruling dogma of the day. 

For the same mode of investigation, which established the frequency 
and variety of alterations of the solids, showed that in many cases 
there was a common character recognized as the result of inflamma- 
tion. This paved the way for the introduction of the so-called 
physiological doctrine, which referred all diseases to alterations of 
vitality in the solids — not generally as affecting the whole system, 
but local — not differing from one another by any special characters, 
but in degree only. A disease was, then, either a plus or a minus 
vitality in the affected organ, and its symptoms were explained by the 
sympathies of that organ. But as so many diseases were attended 
with vascularity, deposition, and increased sensibility, it was inferred 



6 LECTURES ON FEVER. 

that most local affections, and the more important diseases, were ex- 
amples of augmented vitality in the part, producing not only the 
local symptoms but those also which arose from the sympathetic 
irritation. This doctrine spread rapidly, and there were many rea- 
sons why it should do so. Tt was specious, simple, and had for its 
founder a man of extraordinary energy and eloquence. In this world 
any doctrine which is novel and has an energetic and eloquent apostle 
will not want for converts, and Broussais was a man of great talent, 
experience, and practical knowledge. He was, however, deficient in 
reasoning power, and, in my opinion, an imperfect pathological anato- 
mist. The doctrine became popular on the Continent from the facility 
which it promised in the treatment of disease, for as the great majority 
of diseases was symptomatic of the plus vitality of some organ, we 
had only to discover the part in which this excess of life was seated, 
and to modify it, of course, by antiphlogistic treatment. 

When the investigations of Broussais and his followers were di- 
rected to the Examination of fever cases, it was found, on the Continent 
more especially, that local disease frequently existed in the gastro- 
intestinal tube. At once, then, the doctrine followed, that fever 
formed no exception to the rule — that it was symptomatic of a plus 
vitality of the gastro-intestinal tube; and we were led to believe that 
fever could be at once cured by leeching, by starvation, by poultices 
to the bell v, and by such means. 

It is curious that there are some circumstances connected with fever 
which greatly tended to prop up this doctrine. We shall see by-and- 
by, that an essential condition of fever is periodicity ; that it is a 
disease which has a tendency to spontaneous termination at a given 
time. It is like a paroxysm of ague, only prolonged as it were. This 
will give the best idea of fever. This mysterious law of periodicity 
implies that the system has the power of curing itself — that is to say, 
that the diseased action will spontaneously subside either suddenly or 
gradually. Now, it is found that there are a variety of circumstances 
which interfere with the operation of this extraordinary law of spon- 
taneous cure. One of these is the existence of a local irritation in 
anv part of the system. 

We see this remarkably exemplified in cases of ague. We shall 
very often find that in cases of intermitting fever the treatment by 
bark will not succeed; and when we come to inquire the cause of this, 
we find that there is some local inflammation present. If we can 
remove that local inflammation, then the treatment by bark succeeds. 
Broussais appealed strongly to the following fact: that in cases of 
fever, after free depletion of the abdomen, the patients speedily re- 



GENERAL CONSIDERATIONS. 7 

covered. So they did : but the nature of the fact was misinterpreted. 
Those patients had a local secondary disease in the intestine, which 
interfered with, or prevented, the operation of the law of periodicity. 
When that local disease was modified or removed, the law of perio- 
dicity came again into action, and the patient recovered.. The fever 
did not subside because it was symptomatic of a disease of the intes- 
tine; but it subsided because, the disease of the intestine being re- 
moved or modified, it was reduced to its normal state, as it were to its 
state of simplicity, and then the law of periodicity was enabled to act. 

The doctrine of the purely symptomatic nature of fever was re- 
ceived extensively on the Continent, in America, and in England and 
Ireland, but not so extensively in the schools of the two latter coun- 
tries. There was a much greater reluctance to the reception of the 
physiological doctrine in this country and in England than on the 
Continent, or in America, and this is highly creditable to the British 
and Irish medical mind. Many reasons might be adduced to explain 
why this was so, but we shall not enter at length. into them. I may, 
however, observe that English medicine had. received a great degree 
of excellence from the writings of the old masters in England — from 
the writings of Sydenham, Haygarth, Fothergill, and other men of 
that order. These great medical observers had, unknowingly, taught 
the true medical philosophy. They had taught a rational eclecticism, 
and hence they implanted in the minds of the British medical inves- 
tigators great reserve and extreme caution in the reception of new 
doctrines. 

Still, however, upon the younger members of the profession the 
doctrine had a wonderful influence. A large number of the junior 
members of the medical and surgical profession in this country, during 
the last quarter of a century, or perhaps the last half century, were 
strongly imbued with this doctrine, and went forth to practise over 
the world, influenced by the theory of inflammation being the sole 
cause of diseases, and believing that the whole practice of medicine 
was reduced to the removal of local inflammation. 

Another cause, however, I cannot help noticing here. About this 
time, owing to the unhappy and calamitous division of the profession 
into medicine and surgery, arose those corporate distinctions that have 
done so much to retard the progress of science in these countries; 
exclusive schools of surgery sprang up, and consequently, as I ob- 
served at the commencement, a large and increasing number of young 
men were educated without having ever seen a case of fever. They 
were educated in surgery ; they were educated in a surgical ward, and 
were sent forth naturally advocates of inflammation, because they had 



8 LECTURES ON FEVER. 

seen nothing else ; and thus, ill prepared, they went forth to combat 
fever — that disease which numbers more victims than any other — 
over the wide dominions of the British crown, in America, in the 
West Indies, in Asia, in Africa. These men in hundreds— I may 
say thousands — went out ignorant of the fearful enemy they had to 
encounter, and trusting in the teachings which compared the ordinary 
phenomena of ophthalmia, or those of the healing of an incised wound, 
or those of the cicatrization of an ulcer, with the symptoms of that 
terrible group of diseases which embraces the plague, the yellow fever, 
the bilious remittent, the malignant ague, and the typhus fever. 

There is nothing more difficult, gentlemen, than for a man who 
has been educated in a particular doctrine to free himself from it, 
even though he has found it to be wrong. There is something in 
a human mind which renders the reception of a doctrine, if it be a 
bad one, a most dangerous circumstance. It is like the imbibition 
of a particular poison or miasma. We find that some men who have 
been once exposed to the miasmata which induce intermitting fever 
will, for nearly the whole course of their lives, be incapable of getting 
rid of that influence which has been once received. And thus it is 
not only with physical but with moral or intellectual impressions. 

I have said that it is difficult to unlearn. This fastening of false 
doctrine in the mind is one cause ; but there are other causes too. 
The indolence of many men prevents them taking the trouble to 
unlearn. The pride of many men has the same effect; and, above all 
things, there is this, that a very large number of students, not only 
of surgery, but of medicine, although they were taught the technicali- 
ties of the profession — the alphabet of their profession, as it were — 
were not taught what is infinitely more important, namely, how to 
teach themselves. Now, this ought to be the grand object of every 
teacher of medicine, and, indeed, of any science of observation. I 
believe that no man can be fully and entirely taught anything. He 
must teach himself. And what the teacher has to do, and what I have 
ever set before myself as my highest duty, is to endeavour to teach 
you how to teach yourselves. 

We can easily anticipate what the result of all this must have been ; 
and I believe I am not saying too much when I declare that a large 
proportion of the fearful mortality to which our gallant army has been 
subjected in the colonial service has been owing to the circumstances 
to which I now draw your attention — the fact of the medical officers 
going out with erroneous doctrine fastened in their minds. 

This name of inflammation is an unfortunate one, and it is to be 
regretted that it was given to the process in question. It gives the 



GENERAL CONSIDERATIONS. 9 

idea of a fire which must be quenched by its opposite, water; of a heat 
which must be quenched by its opposite, cold ; of vascularity — ful- 
ness of the bloodvessels — which must be met by measures which will 
empty those vessels. It gives the idea of a fever, an excitement which 
is only to be met by abstinence, by starvation, or, as the French term 
it, dilte absolue, which means no diet at all. The fact is, gentlemen, 
that the formula of contraria contrariis has as little title to respect in 
legitimate medicine as that of similia similibus in quackery. Both are 
false ; and I really believe that any exclusive application of either for- 
mula is both ignorant and mischievous in the highest degree. 

The next great error was, that although the surgical student had 
plenty of opportunities of seeing symptomatic fever, he had no oppor- 
tunity of seeing the essential fever, and he naturally confounded the 
two together. And hence, in this country and abroad, for many years 
the abuse of the antiphlogistic treatment was carried to an extent which 
it is frightful to contemplate. Conditions of the system which required 
wine, bark, stimulants, careful nutrition, were met by the lancet, by 
leeches, and by starvation. I remember when I was a student of the 
old Meath Hospital, there was hardly a morning that some twenty or 
thirty sufferers from acute local disease were not phlebotomized. The 
floor was running with blood ; it was dangerous to cross the prescrib- 
ing hall for fear of slipping; and these scenes continued to be wit- 
nessed for many years. The cerebral symptoms of typhus fever were 
met by opening the temporal artery, or by a large application of leeches 
to the head ; and it sometimes happened that the patient died while the 
leeches were upon his temple — died surely, and almost suddenly. An 
eminent apothecary in this city assured me that when he was serving 
his apprenticeship there was hardly a week that he was not summoned 
to take off a large number of leeches from the dead body. I mention 
these circumstances to show to what extent, even in our own country, 
the abuse of this doctrine had been carried. It is not so now. Those 
who have been in the habit of attending fever hospitals in this country 
will bear me out when I say that the lancet is an instrument now very 
seldom indeed employed in our wards. But while all this is true, it 
must be understood that I am far from going the length of some 
modern physicians in their wholesale condemnation of the antiphlo- 
gistic treatment in various forms in the management even of essential 
fever. To this subject I purpose to return in my next lecture. 



10 LECTURES ON FEVER. 



LECTURE II. 

Change of Practice as regards the treatment of fever — Change of type in disease from 
sthenic to asthenic — Views of Alison — Sir Robert Christison — The author's views 
— Evidence (1) from symptoms, (2) from appearances of blood drawn by venesec- 
tion, (3) from pathological appearances of internal viscera, and of serous mem- 
branes. (4) from isolated sthenic leases, and (5) from influence of treatment — Signs 
of a return to sthenic forms of disease — Vital character of disease. 

Based on the doctrine that local inflammation or irritation was the 
exciting cause of febrile disease, we observe the wide-spread adoption 
of an antiphlogistic treatment in fever. The doctrine of essentiality 
of disease was ridiculed. Venesection in fever was common, and its 
traditional employment was supported by modern theory; the use of 
wine and other stimulants was forbidden, and many a life was sacri- 
ficed to this unphilosophical method of looking at disease. 

But for nearly half a century we observe a change in practice in 
the opposite direction. General blood-letting is rarely practised; local 
bleeding in a very modified way ; while stimulants have been, by one 
school, clearly employed in an unjustifiable manner. 

So complete was the change in practice, that venesection, from being 
a routine treatment, the performance of which was entrusted to junior 
students, became the rarest of surgical operations. Within the last 
twenty years I have known several surgeons who had never performed 
or even witnessed the operation. I remember having to instruct a 
hospital surgeon of remarkable ability in the operation. For a period 
of nearly twenty years the use of the lancet was unknown in our 
wards, and in latter times, when venesection was occasionally prac- 
tised here, it was instructive as well as amusing to see how the class 
crowded round to witness for the first time a proceeding so unusual. 

We can hardly conceive a revolution in practice more complete. 
In place of the loss of blood we have the exhibition of stimulants. 
In place of a system of almost starvation we have the careful use of 
nutriment. 

This change in practice, depending on change in the vital character 
of disease, was followed by the charge against many of our predecessors 
and teachers that they were mistaken practitioners, ignorant of true 
pathology, and little better than blind followers of traditional error. 
Not only have their powers of observation been questioned, but even 



GENERAL CONSIDERATIONS. 11 

their morality and honour have been assailed ; and it has been suggested 
that the whole doctrine of change of type in disease was an invention 
to cloak former errors. 

It is interesting to note that this is not the first time that charges 
of a similar kind have been brought against the profession. Thus 
Broussais arraigned the existing and former practitioners for not treat- 
ing fevers and acute diseases by local bleeding and starvation. Can 
there be stronger evidence than this that our modern practice is not a 
novelty ? All his predecessors were in error; because they practised 
as we do now. I say that this charge was remakable, inasmuch as the 
author's views largely influenced European practice for many years. 

But the thinking man finds it hard to believe that the fathers of 
British medicine were always in error, or that they were bad observers 
and mistaken practitioners. They, indeed, have rested from their 
labours, but their works remain ; and he who reads the writings of 
Sydenham, of Haygarth and of Fothergill, of Heberden and Fordyce, 
of Gregory, Cullen, Alison, Cheyne, or Graves, must have a very 
inapprehensive mind, if he fail to discover that there were giants in 
those days, and that the advocacy of such ideas only indicates a state 
of mind not consonant with the modesty of science. 

The declaration that it has been or can be proved by a more 
advanced pathology that bleeding never was the proper remedy for 
fevers and inflammations has as yet no scientific ground. It is not 
yet given to us, notwithstanding all our advance in normal and in 
morbid anatomy, in the physiology of health or of disease, to be able to 
say, from the most minute examination of the dead organ or structure, 
what were all the conditions which attended it during life, under the 
influence of disease; what were its local vital phenomena; what was 
the accompanying constitutional state, whether sthenic or asthenic. 

But, let us ask, which is the more probable of these two supposi- 
tions? First, that our predecessors were bad observers, incapable of 
divining the truth, and blind adopters of an antiquated and mis- 
chievous method — or, secondly, that the type of disease has changed, 
and that almost in our own time. It fortunately happens that we 
can examine a living witness of great authority in this matter, and 
can refer to the works of two more who have left us their written 
testimony. Sir Kobert Christison is still among us, in health and 
intellectual vigour — long may he be so — Dr. Alison and Dr. Graves 
have been but lately removed. 

Now, all these testify that the character of disease has changed from 
a sthenic to an asthenic type ; that is to say, from a condition in which 
inflammatory action was the prominent feature to another where that 



12 LECTURES ON FEVER. 

state was absent, or, if present, only ephemeral — a condition observ- 
able in essential and local diseases, in which the antiphlogistic treat- 
ment agreed well, and was productive of great relief, to one in which 
a tonic, stimulant, and supporting regime was found the best method 
of guiding the system to a happy termination of the disease. 

It is very important to note that these views were not formed from 
any historical study of the recorded labours of others, but come before 
us as the actual observations of the great men whose names I have 
stated. They tell us that which they know — that which they them- 
selves have seen. If we refuse this collective though separate and 
independent evidence— if we hold, with Professor Bennett and with 
Dr. Markham, that the doctrine of change of type is untenable — we 
must believe one of two things : either that these distinguished men 
were deceived or were themselves deceivers. From this alternative 
there is no escape. 

Let us hear Dr. Alison: " 'When we reflect on these facts, we can- 
not think it unlikely that the result of the inquiry which I have stated 
as so important may be to show either that all causes capable of excit- 
ing diseased action in the animal economy, or, more probably, that 
the liability to diseased actions in the different departments of the 
animal economy itself, are subject to variations, which are made 
known to us only by the variation of such phenomena themselves; 
occurring merely in the natural course of time — an element affecting 
all vital phenomena quite differently from its agency on inanimate 
nature; and the effects of which, on living beings, we must take as 
ultimate facts, to be carefully observed, arranged, and classified, but 
which we are not to expect to be resolved into any others, which the 
study of this department of the works of Providence presents." 

When I read these words of Alison, the best man I ever knew, it 
is with a feeling of wonder how it has happened that men should 
forget what reverence is due to his memory, whether we look on 
him personally as a man of science and a teacher; or at his life as 
an exemplar of that of a soldier of Christ. 

Sir Robert Christison 1 shows that the change of treatment in acute 
diseases is to be considered with reference to fever as well as to local 
affections. He bears witness that the abandonment of bleeding in 
idiopathic fevers preceded by a good many years its abandonment in 
acute inflammation ; and that this change in practice took place gradu- 
ally in all acute inflammations, not alone in pneumonia, because of the 
improved diagnosis of the disease, but in all others, in many of which 

1 Memoir on the Changes which have taken place in the Constitution of Fevers and 
Acute Inflammation in Edinburgh during the last Forty-six Years. 1856. 



GENERAL CONSIDERATIONS. 13 

no sensible progress in diagnosis had been made. Looking at the 
fever epidemics of Edinburgh from the beginning of the present cen- 
tury, he shows conclusively that in 1817-20, and in 1826-29, their 
characters were those of Cullen's synocha and synochus — inflamma- 
tory, relapsing, critical. 

Speaking of the epidemics of 1817-20, he dwells on the hard, in- 
compressible pulse, the ardent heat of the skin, the florid hue of the 
venous blood and the impetus with which it escaped almost per saltum 
from the vein, the vivid glow of the surface, and the distracting pain 
and pulsation of the heart and chest. 

Similar phenomena occurred in the epidemic of 1826-29, and in 
both bleeding was largely practised with the happiest effects; so that 
in the former epidemic the mortality, which was at first one in twenty- 
two, fell to one in thirty — a result which disposes of the charge of 
malpraxis against the profession. 

But in 1834 Sir Eobert found that probably for two years pre- 
viously a change had been going on ; synocha had disappeared ; 
synochus had lost the vehement reaction of its early stages; typical 
typhus was much more common ; and what did not come up to 
Cullen's mark of fully formed typhus was what physicians would 
now commonly call mild typhus, with more of introductory reaction 
than we observe at present, but with less than in the two epidemics 
of 1817-20 and 1826-29. 

"In epidemic fevers," says this distinguished physician, "a change 
may take place in the constitutional part of the fever; and this change 
has been exemplified in Edinburgh during the last forty years, by a 
transition from the sthenic or phlogistic character in the first twelve 
years to the asthenic or adynamic character in the twelve years which 
have just elapsed." 

And he adds these most remarkable words : — 

" If this change be admitted to have been proved, there is an end 
to all difficulty in accounting for the abandonment of blood-letting in 
the treatment of our fevers. In point of fact, I am able to state very 
positively that the abandonment of bleeding in fever was suggested 
by the observation of a change in the constitution of fever, and in the 
effects of the remedy on it, and not by any other circumstance, 
whether extraneous or intrinsic. It is impossible to ascribe such 
change of practice, as Dr. Bennett has done in the instance of pneu- 
monia, to an improved knowledge of disease. We have improved 
our knowledge of fever so far as to have been for some time well 
acquainted with the form of enteric typhus (dothinenteritis), which 
was unknown, or not recognized, at the commencement of our epi- 



14 LECTURES ON FKVER. 

demies. Bat this is a rare form of fever in Edinburgh, scarcely 
belonging to its epidemics at all. And as to our only undoubted 
epidemic fevers, typhus and synocha with their intermediates, we 
cannot be truthfully said to be the better acquainted with them in 
1857 than we were in 1830. 

"I have given, I hope, a sounder explanation, less flattering per- 
haps to the rising generation of physicians, but surely more honour- 
able to physic itself, more creditable to medical observation and 
experience, more consonant with the advanced state of medical 
philosophy. My own convictions on the subject are so strong that I 
regard nothing as more likely than that in the course of time some 
now present will see the day when a reflux in the constitution of 
fever will present it again in its sthenic dress, and again make the 
lancet its remedy. And in that event it is not impossible that, while 
we are now charged with giving up blood-letting, because it was dis- 
covered to have never been the proper method of cure, we shall 
hereafter be assailed by some new enthusiast in blood-letting, who, 
in imitation of Dr. Welsh, and regardless of the fate of his doctrines, 
will accuse us, with equal justice, of having our late fevers asthenic 
and typhous by blindly withholding their fittest remedy." 

Since the delivery of my address on " Change of Type in Disease" 
before the British Medical Association at Leamington, in the year 
1865, I have received numerous letters on the subject from many 
leading physicians in England and Ireland. The testimony of these 
gentlemen has been of the strongest character in favour of the occur- 
rence of an asthenic type of local inflammatory disease within the last 
forty years. 

That the type of both local and essential disease varies within 
certain limits of time we must believe. That a more asthenic form of 
disease has for nearly half a century prevailed in these countries is, I 
hold, an incontrovertible truth, and a time may come when those 
whose experience is of a later date will speak of the practice of their 
predecessors with greater modesty and more reverence. 

T may now add the results of my own experience in this matter. 
I remember the period when the change of type took place in Ire- 
land, and am under the impression that it was observed earlier in this 
country than in Scotland, or at least in England. The great epidemic 
of fever in 1827 was a remarkable one from its compound nature, 
and seemed to be made up of synocha, synochus, and enteric typhus. 
But nothing was more remarkable than the vehemence of the inflam- 
matory reaction in many cases; and it is a curious fact that this was 
sometimes seen at its highest pitch in the relapses, when it was often 



GENERAL CONSIDERATIONS. 15 

t 

far more violent and dangerous than in the first attack. Local bleed- 
ing was largely employed. In many cases venesection or arteriotomy 
had excellent results; so that, although there were abundance of cases 
with prostration, and others marked by the typhoid condition, the old 
sthenic character had not disappeared. The amount of wine used at 
that time in hospitals was quite insignificant as compared with its 
consumption in more recent times. 

Between 1822 and 1828 the sthenic character of essential and local 
disease existed, and the lancet was freely used — often, as I believe and 
have elsewhere stated, with too great freedom. But I well remember 
observing the frequent occurrence of the phenomena mentioned by 
Sir Robert Christison — the vehement action of the heart, the incom- 
pressibility of the pulse, the vivid redness of the venous blood, and 
the force with which it spouted, almost per sallum, from the orifice in 
the vein. I have myself taken as much as sixty ounces in a case of 
active cerebral congestion, with hemiplegia, before any impression 
was made on the arterial excitement; in this case complete success 
followed. In rheumatic fever, too, we found the use of the lancet in 
the early stage of the disease to be productive of great relief. Vene- 
section was seldom employed more than once, but its effect was to 
shorten the duration of the disease, to lower the fever, to lessen the 
liability to the so-called metastases, and to render the whole case much 
more amenable to treatment. 

But I have not bled in rheumatic fever for the last thirty years, for 
the whole character of the disease has changed. We have not had for 
many years the bounding pulse, the exaggerated heat and sweating, 
or the same liability to acute inflammations of the internal parts. The 
action of the heart is often feeble, and the tonic and supporting plan 
seems called for from an early period. Another point worthy of 
remark is, that cardiac and aortic murmurs of the anasmic kind have 
for many years been much more frequently observed, both during 
the attack and in the convalescence, and these demand the use of iron 
for their removal. 

In judging of this question the evidence of those who have been 
intimate with acute diseases in this country during the period of 1820 
to 1830 or 1835 must be attended to on this point. As already stated, 
I have received a vast number of communications from experienced 
and practical men, who had no theory to support, all telling the same 
tale, all testifying to the fact that a change in the vital character of 
acute disease was observed. This was particularly seen in rheumatic 
fever, which gradually lost its quality of high reaction, as shown by 
the great heat of the skin, the bounding and resisting pulse, the vigour 



16 LECTURES ON FEVER,, 

of the heart's action ; the frequency and severity of metastasis, not 
only as regards external but internal structures whose functions were 
violently disturbed. Cases, too, of visceral inflammation, independent 
of rheumatic complication, and marked by high reaction, pain, and 
great functional disturbance, were common. This was well seen in 
the cases of pleuropneumonia, in pericarditis, and in peritonitis, in 
all of which violence of symptoms, high reaction, and great pain and 
rapidity of morbid processes were the rule. Now, since the asthenic 
character of acute disease has set in, all this has changed. The violent 
acute and commonly suppurative pneumonia is rarely met with. We 
frequently meet cases of pericarditis in which, but for the physical 
signs, the disease could not be recognized, or its being overlooked 
would be excusable — you have seen many cases with little or no 
oppressive distress or throbing of the heart. And as to acute peri- 
tonitis, formerly so well known, there has rarely been seen in any of 
our wards a case of it that did not result from the perforation of the 
intestine in enteric fevers. 

It is needless to add examples; let us rather turn to another kind 
of evidence. Hitherto the change of type has been recognized and 
determined less by anatomical observation than by the observation of 
symptoms, and still more by the application of therapeutical tests. 
Kemedial measures of a certain kind were found to fail and to be 
hurtful, where they were formerly safe and successful ; and, conversely, 
the use of a supporting system of tonics, and the free employment of 
stimulants, were found necessary and safe where formerly they did 
mischief. 

That morbid anatomy adds its testimony to the truth of the doc- 
trine of the change of type in disease will, I believe, appear from 
considerations based on observed facts. Thus, after or about the time 
when an asthenic tendency was first noticed in Ireland, a change was 
detected in the condition of the blood drawn by venesection. The 
buffed and cupped character became very rare, and I well remember 
expressing my surprise at the absence of the fibrinous coat in cases 
in which we had fully expected its presence. In place of the small, 
dense, almost spherical crassamentum, we had a soft clot, with little 
if any separation of serum ; while, instead of the buffy coat with 
inverted edges, we had a thin sizy pellicle. This circumstance was 
one of those which led us to be more aud more cautious in the use of 
the lancet. 

Again, the specimens of acute disease have had for many years a 
character very different from that commonly met with in Dublin 
between 1820 and 1830. As a general rule, these specimens all 



GENERAL CONSIDERATIONS. 17 

showed appearances indicative of a less degree of pathological energy. 
In pneumonia, for example, the redness, firmness, compactness, and 
defined boundary of the solidified lung was seldom seen ; and that 
state of dryness and vivid scarlet injection, to which I ventured to 
give the name of the first stage of pneumonia, became very rare. In 
place of these sthenic characters, we have had a condition more 
approaching to splenization — the affected parts purple, not bright red; 
friable, not firm ; moist, not dry ; and the whole looking more like 
the result of diffuse than of energetic and concentrated inflammation. 

Let us now turn to the serous membranes, and the same story is 
repeated. The high arterial injection, the dryness of the surface, the 
free production, close adhesion, and firm structure of the false mem- 
branes in acute affections of the arachnoid, pericardium, pleura, and 
peritoneum, which had been so familiar, ceased in a great measure to 
make their appearance. The exudations began to assume a more or 
less hemorrhagic phase, serous or sero-fibrinous effusions tinged with 
colouring matter replacing the old results of sthenic inflammations. 
The effused lymph lay like a pasty covering, rather than a close and 
firm investment as before; it was thin, ill-defined, and transparent in 
varying degree. All this tallied exactly with the change in the vital 
character of the disease. 

It has happened to me — and I mention this in evidence that we were 
not mistaken with reference to cases of the sthenic character — that a 
few instances of disease in its old phase of high inflammatory reaction 
have appeared in isolated examples and at irregular intervals of time, 
so that we at once recognized their nature, and employed with success 
the old treatment in all its vigour— employed the lancet, though for 
many years it had been laid aside. This is important as showing 
that there are influences, their nature as yet unknown, which affect 
the vital character of local disease in an inconstant manner. 

During the last few years we have not been without signs of a 
return to the old sthenic forms of disease. Even fifteen years ago a 
typical case of the old form of acute pleuropneumonia occurred in 
this city in the practice of the late Dr. Oroker. The symptoms were 
those of the highest inflammatory reaction, attended by violent excite- 
ment of the heart. There was great pain and dyspnoea, a bounding 
pulse, a burning skin, and the rusty and tenacious sputa which for 
many years had not been seen in our hospital wards. This patient 
was treated by free venesection, copious leeching, and the exhibition 
of tartarated antimony; and though the lung had passed largely into 
consolidation, the patient made a complete and rapid recovery. Cases 
of a similar kind have reappeared in our wards during the last three 
2 



18 LECTURES ON FEVER. 

years, and the use of the lancet, which for a quarter of a century was 
unknown with us, has been on several occasions resumed, and in all 
such cases with the very best results. The relief has been always 
immediate, the resolution of the disease, as shown by physical exami- 
nation, generally rapid, and the convalescence, with one exception, 
most satisfactory. In three out of four cases the treatment consisted 
in one bleeding, which sometimes was followed by the application of 
six or eight leeches to the seat of pain. No further treatment beyond 
the use of the simplest palliatives was employed. 

Must we not, then, agree with Sir Kobert Christison that the disuse 
of venesection, so remarkable in these countries during a period of 
about forty years, is wrongly appealed to as evidence of our advance 
in the healing art? We are not to hold that the former practice of 
venesection was improper or unscientific; and while we admit that, 
under the influence of old custom and the anatomical theory of disease, 
blood-letting was abused in many cases, we must be careful not to drift 
into the opposite error of neglecting this remedy where it is called for, 
nor be guilty of the folly of holding that the physicians of the past 
two or three generations were bad observers and harmful practitioners. 
That they were men of truth is obvious to every one who understands 
disease, and who takes at its proper value the opinion of those who show 
such overweening confidence in the present so-called pathological 
medicine — so much based upon mere structural and chemical changes 
— and such neglect of some important medico-ethical considerations, 
as, for example, the modesty of science and the practice of a reve- 
rential spirit towards those whose works prove that they were great 
and truthful men. 

The change of type is to be seen in the character of the symptoms 
and, as I have endeavoured to show, in the condition of the patho- 
logical changes. But it is to be recognized chiefly by the therapeu- 
tical test, by the behaviour of disease, whether general or local, under 
treatment. It may be well to repeat that the change seems to date in 
the present century from about the time of the first invasion of cholera, 
and has continued more or less ever since. 

The change from sthenic to asthenic (so far as we at present know) 
is one more of the vital than of the structural or chemical characters 
of disease. The symptoms indicate, as it were, a lower tension of all 
the vital phenomena. The convalescence is less perfect and slower, 
as are also the physical signs of the resolution of local disease. The 
capability of bearing a reducing treatment is singularly diminished. 
Local lesions exhibit a greater latency. The nervous system shows 



GENERAL CONSIDERATIONS. 19 

earlier signs of depression, while tonics or stimulants have been 
better borne. 

So far as medical experience goes, we are forced to admit that the 
foundation for the healing art must rest on another, if not a broader, 
basis than that of anatomical and of chemical changes in disease. 
There are differences — and for want of a better name we may call them 
vital — which more intimately relate to life and health than to the 
anatomical or chemical changes produced by disease; and these are 
to be reached by the study of the living phenomena of the body, and 
of the influence of agents upon them. In truth, the fruitless attempt 
to base medicine upon anatomical or even chemical changes should 
be a lesson to those who neglect the infinitely varied mutations of 
vital or of nervous action. 

The healing art, whether medicine or surgery, requires a wider 
field of study than is afforded by the dissecting-room or the laboratorj^. 
The anatomists, the histologists, and the chemists of some of the 
modern schools of medicine would derive a deep practical lesson from 
the words of Goethe, 1 who says, alluding to the insufficiency of mere 
anatomy to explain the mysteries of life — 

For he who seeks to learu, or gives 
Descriptions of, a thing that lives, 
Begins with " murdering, to dissect," 
The lifeless parts he may inspect — 
The limbs are there beneath his knife, 
And all — but that which gave them life ! 
Alas ! the spirit hath withdrawn — 
That which informed the mass is gone. 
They scrutinize it, when it ceases 
To be itself, and count its pieces, 
Finger and feel them, and call this 
Experiment — analysis. 

The study of normal anatomy being then fruitless in solving the 
problem of healthy life, it might be anticipated that researches as to 
morbid structure have thrown but a fitful and limited light on disease. 
In truth, the knowledge of Curative or of Preventive Medicine is not 
to be learned in the dissecting-room of a medical school, or in the 
dead-house of a hospital. Until this truth be acted on, many precious 
years of the best time of the student's life will be wasted. It has been 
attempted to base medicine on pathological anatomy, as if by its study 
we could solve the infinitely varied problems of disease and of thera- 
peutics. The explanation of even death through anatomical research 

1 Faustus. Translated by John Anster, LL.D., of Trinity College, Dublin. 1835. P. 
120. 



20 LECTURES ON FEVER. 

is admissible only in exceptional cases. But it is of value — less as a 
key to the origin and cause of disease, than to diagnosis and the 
science or the many changes which attend morbid action. 



LECTURE III. 

Fever described, but not defined, as " a condition of existence without any known or 
necessary local anatomical change and subject to new laws, different from those of 
health" — Error committed by the school of Broussais — The " Law of Periodicity" — 
Danger to the fever patient due to the primary disease or to its secondary compli- 
cations — Secondary affections of continued fevers more inconstant than those of 
the exanthemata — Classification of diseases: (1) Diseases having an anatomical 
character ; (2) neuroses, having no known anatomical character; (3) fevers, subject 
to the law of periodicity, causing secondary affections, transmissible by contagion 

Fever is a condition more easily described than defined, and it is 
far easier to declare what it is not than what it actually is. During the 
continuance of a fever the system seems, as it were, to enter upon a 
new and special phase of existence. Most, if not all, functions are 
liable to be either interrupted or modified in a varying degree, and 
this possibty without the occurrence of any local anatomical change. 
We cannot say, I believe, what fever is in its essence, yet one thing 
appears certain — that it is not symptomatic of the organic changes 
which may be found combined with it, but is rather the generator and 
governor of those affections. It is, then, a condition without any 
known or necessary local anatomical change. 

It is true that in certain forms of fever there are secondary mani- 
festations of local disease. The pustulation of the skin in variola, 
the ulceration of the intestine in the so-called typhoid, and the bron- 
chial congestion in typhus, are examples of these conditions. But 
looking at fever in a wide sense, we may safely hold that these sec- 
ondary anatomical changes are inconstant in their amount, in their 
nature, and even in their seat; inconstant as to their time of appear- 
ance, their symptoms, their intensity, and their decadence, and utterly 
incompetent to explain the phenomena of the disease. 

The great fact remains, that in epidemics of fever cases arise in 
which, after the general symptoms have run their course, so as to 
present a perfect specimen of the general disease, we may dissect the 
brain, spinal marrow, nerves, the pulmonary and gastro intestinal 
mucous membrane, the liver, every organ you please, and find no 
anatomical change. I believe we may say that when the fatal diseases 



THE LAW OF PERIODICITY. 21 

of the world are considered, the most destructive are those which have 
no recognized anatomical character. You may believe that when we 
speak of fever generally, secondary lesions are either wanting or are 
inconstant in their amount or in their nature. Upon their incom- 
petence to explain the matter I have already remarked. 

It will naturally be asked, If this be so, how did the French school 
commit the extraordinary error of declaring that a special anatomical 
change characterized every case of fever ? The reason is simply this : 
they committed two grave errors in medical philosophy: first, in 
confounding the effect with the cause; and secondly, in assuming the 
nature of a disease over the world from its observation in one locality. 
Had Broussais and his followers studied fever in Ireland, Scotland, 
or England ; had they gone abroad and examined it in the East or 
West Indies, or on the coast of Africa, we should have heard little of 
the doctrine that fever was not essential, but only symptomatic of this 
or that local inflammation. 

Observation has long shown that fever is a state of existence under 
a law of periodicity, and this is more or less true as to the general 
affection and as to its local results, though this law is more often 
manifest in the case of the former than in that of the latter. In the 
disease, I believe under any of its forms, two sources of danger affect 
the patient. One of these is death from simple depression of all the 
vital powers; for the poison of fever, like that of the rattle-snake, has 
a directly depressing influence on the system. Another source of 
danger is the production of secondary diseases. A general notion of 
this will be best obtained by considering an ordinary case of small- 
pox. The patient is taken ill ; he has shivering, fever, pain, vomiting, 
and so on ; and then we observe vesicles on the surface, these vesicles 
filling with pus, afterwards drying, and then disappearing. No man 
will say that the fever was symptomatic of the eruption. It is exactly 
the reverse ; the eruption was the result of the fever. So it is in fever ; 
the local disease is the product of the general. There is, however, 
this difference between what we term continued fever, typhus, or 
typhoid, and the exanthemata, that while in the latter the local affection 
is almost always accompanied by certain characters, it is not so with 
respect to the secondary diseases of the fevers specified. However, 
between the exanthemata and typhus fever there is this point of 
resemblance, that the secondary affections are utterly incompetent to 
explain the general phenomena of the disease, while in typhus, and, 
I believe, in typhoid, they are doubly inconstant in their seat, their 
nature, and their amount — and this is true even in cases occurring 
during the same epidemic. But they are of very great importance. 



22 LECTURES OX FEVER. 

It may be asked, Are they inflammations? I believe they are not 
inflammations, or, if they be such, they have a specific character. 
Certainly in their first stages they are not inflammatory ; but in many 
instances, after they have existed in their non-inflammatory state, 
there comes on a reactive irritation, so that we may then have a mixed 
condition of essential and symptomatic fever. In my opinion this is 
the history of the ulcerations of the intestine so common in typhoid 
fever, for in the beginning — as in variola — we often find tumefaction 
and infiltration without increased vascularity. It has been proved 
that in many cases the morbid process goes no further, and we have 
retrocession of the infiltration, as we see retrocession in the eruption 
of smallpox. 

It may be laid down that while the great majority of separate 
diseases catalogued in books have an anatomical character, fever is 
wanting in this particular with regard to the practice of medicine. 
We may, then, divide diseases into three great classes. 

In the first class we have diseases which have an anatomical cha- 
racter — diseases to which we can give an anatomical expression. I 
need not occupy your time in giving examples of this class. 

In the next place, we have a most important class of diseases which, 
in the present state of our knowledge, cannot be connected with any 
recognized anatomical character, and yet they are not fevers. I allude 
to the neuroses, or, as they are commonly termed, nervous affections; 
of these mania, epilepsy, lock-jaw, hydrophobia, hysteria, chorea, con- 
vulsions, are familiar instances. Here we have some most remarkable 
affections, which have not any known anatomical character; that is to 
say, we cannot yet show that they depend upon any known or ascer- 
tained anatomical change of any portion of the system, including the 
brain, spinal marrow, and nerves. The general character of this 
singular group of affections, which we call neuroses, shows that, what- 
ever be the nature of the disease, the seat of it is in the nervous system ; 
but, in the present state of anatomical knowledge, we are not justified 
in saying what the condition of the nervous system is to which they 
owe their origin ; whether it is an organic change at all, or whether, 
supposing such a change to exist, its amount is proportionate to the 
violence of the symptoms. Even the results hitherto obtained by the 
microscope have been chiefly negative ; the microscope has added but 
little to what was before known on those subjects. I may state here, 
lest you should fall into a misapprehension, that I do not wish you to 
believe that organic change is not found in any of these diseases. 
The fact is, that in many of them such does exist; but when we come 
to inquire what those organic changes are, we find that they are so 



FEVERS AND NEUROSES. 23 

inconstant, so variable, frequently so similar in opposite diseases, that 
they have hitherto altogether failed to throw any positive light upon 
the subject. 

This, then, is the second class of diseases; the first class having an 
anatomical character, the second having no anatomical character. 
Now we come to the third class, which comprises fevers. Fevers, as 
we have already said, have no anatomical character. Then, it will be 
asked, how do they differ from the neuroses? As far as we know, and 
strictly speaking, they differ very little ; but there is this feature con- 
nected with them, that fever seems to be a special condition of life 
which is to exist for a certain time, and then to cease— that is to say, 
it is under the law of periodicity; and in this respect the phenomena 
of fevers differ very much from those of the pure neuroses. There 
are other differences, too, between fevers and neuroses. It is quite 
true that in a large number of fevers death may take place without 
any organic change that we can demonstrate anatomically; but it is 
true, on the other hand, that in a large number of cases there is a 
tendency to the development of what are to be designated the secon- 
dary lesions of the disease. Thus, if we compare these two classes, 
the neuroses, which are not fevers, and the fevers properly so called, 
we find this great difference, that among the former (as for example 
in hydrophobia) we do not see any tendency to the development of 
ulcers of the intestine; in epilepsy we do not find any tendency to 
the development of bronchial diseases; in mania we do not see a 
cutaneous eruption ; in convulsions we do not find any of these various 
organic changes produced. This tendency, then, to generate or pro- 
duce local anatomical changes secondary to the fever is another re- 
markable distinction between this class of affections and the pure 
neuroses. 

There is a third very remarkable distinction between them. Fevers 
— using the term in a general sense, embracing, as I have already 
pointed out, a great number of essential diseases, as the exanthemata, 
typhus, plague, and yellow fever — are capable of being transmitted 
by contact or by vicinity; many of them — J believe almost all— are 
more or less contagious. So that in their subjection to the law of 
periodicity, in their liability to generate or produce various organic 
changes in different parts of the system, and in their transmissibility 
by contagion, we have three very important distinctive characters, 
although we cannot reduce them to an anatomical expression. 

A great deal has been written on the subject of the proximate 
cause of fever, and theory upon theory has been promulgated. We 
are, however, at this moment as ignorant of the proximate cause of 



24 LECTURES ON FEVER. 

fever as we were in the time of Cuilen, or even long before him. It may 
be expected, however, looking at the advance of medical knowledge, 
that the proximate cause or causes of fever will yet be discovered ; 
but it is a general and justifiable opinion that essential fevers result, 
in most cases, from the introduction of a poison into the system. The 
whole of the phenomena of poisoning by organic matter seem to point 
out a close analogy between fevers and those diseases in which a 
poison is introduced into the system. If a man who is in perfect 
health is exposed to the contagion of syphilis, in a short time his 
system becomes a laboratory for the formation of syphilitic poison, 
and he is capable of communicating the disease. As far as we can 
form a judgment on this question we may say that there is a very 
close analogy indeed between fevers and toxic diseases, whether they 
be fevers which are the result of contagion or not; and in this way we 
see a connecting link between fevers, which we call acute diseases, 
and diseases which are neither acute nor febrile. Thus, for example, 
we do not say that a patient who is labouring under syphilis, which 
he has caught by contagion, is in fever; but he is, nevertheless, under 
a condition which, so far as the chemico-vital state of his body is con- 
cerned, is somewhat analogous to fever ; that is to say, his system has 
received a poison, and having received that poison, it seems to work 
upon it, or the poison to work on the system, and the result is that 
the system becomes a generator of the same poison that it has re- 
ceived. 

Now let us go a little further into this subject. I might give 
various other illustrations; and, indeed, I think you will find that 
some unexpected analogies will arise in this matter, and that you will 
even perceive an analogy between two such opposite diseases — such 
dissimilar diseases as typhus fever and pulmonary consumption. For 
there can hardly be a doubt that, under certain circumstances, tuber- 
cular matter introduced into the system acts like contagious matter, 
and that it produces a development of tubercular disease in the system 
thus infected. Such cases, then, may be considered as examples, if 
you will, of very chronic fevers, long-continued fevers, and fevers 
which are not, apparently at least, under the influence of the law of 
periodicity. I am perfectly persuaded that the more we study that 
class of diseases, which seems to be general rather than local, we shall 
find that the possibility of contagion will be more and more exhibited. 
I am strongly of opinion that the majority of the acute essential dis- 
eases are contagious, and I think it certain that there are other diseases 
also which we do not call fevers that are contagious. It is hardly 
possible to doubt the contagiousness of cholera ; and we may go still 



FEVERS AND TOXIC DISEASES. 25 

further, and extend the possibility of contagiousness even to such dis- 
eases as tubercular affections, and perhaps even further. 

We know that scarlatina, measles, and smallpox are generally con- 
stant in their phenomena, and especially in the phenomena of their 
secondary changes — so much so that in them the secondary change 
is taken as a distinctive mark of the disease. These affections are 
probably, as I said before, more directly contagious; and it becomes 
a question whether this may arise from the circumstance that the 
matter of contagion in these cases is more elaborated — is perhaps 
more perfect according to its kind — or whether greater facilities are 
afforded for the conveyance of contagious matter during the desqua- 
mative processes so common in these diseases. The patient who con- 
tracts the disease is very much in the same position as a person who 
contracts syphilis; that is to say, that an organic poison of a special 
kind, whose essential characters, however, are so subtle as to escape 
chemical investigation, has been presented to his system and has 
affected him. The phenomena of typhus and typhoid are more 
variable ; and this may arise from the want of constancy in the exciting 
cause. We can hardly suppose a man to get smallpox unless he has 
been infected by another who has had smallpox. But continued 
fever, or typhus fever, seems capable of being produced by a great 
number of causes, or, if I may so speak, by a number of imperfectly 
developed or imperfectly acting causes, and these, of course, may be 
infinitely various. We also see this very curious difference between 
typhus fever and the exanthemata, that while among exanthemata, so 
far as we know, the one exciting cause produces its own disease — the 
exciting cause of smallpox producing smallpox, that of scarlatina pro- 
ducing scarlatina, that of measles producing measles — this does not 
seem to be the case with respect to fever. For here is one of the most 
important and interesting facts connected with the entire subject, that 
the same exciting cause — at least as far as we can see of it — is capable 
of producing different kinds of fever in different persons. This great 
fact has not been sufficiently dwelt on by the various writers on fever 
on the Continent and in England, especially by that class of men 
whose object seems to have been to make themselves classifiers of 
diseases — makers of classifications — at which nature laughs. 

Here is another of the great facts which show the inexpediency of 
drawing hard and fast lines of distinction between what are termed 
typhus fever and typhoid lever — that the one exciting cause will in one 
person produce one form of fever and in anotheradifferent form of fever. 
Now, we see nothing of this sort in the exanthemata. What may be the 
reason of this it is diificult to say; and we explain it very often by 



26 LECTURES ON FEVER. 

expressing the fact in different words. It is supposed that it may be 
due to some variation in the state of receptivity of the body at the time. 
For in the production of the effect of the poison there are two elements: 
first, the nature and composition of the poison which is to act; and, 
next, the chemico-vital state of the body which is to be acted on. The 
two causes combined produce the result — -fever. But if, the cause 
being the same, the bodies be in different states, we may expect dif- 
ferent kinds of fevers; and this is all that we can say on the subject. 

Now let me address especially the junior members of the class, or 
those who have hitherto worked exclusively in the surgical wards. I 
want them to look on the local acute diseases of fever as they would 
look on the pustules of smallpox, the efflorescence of erysipelas, or the 
eruption in measles or scarlatina. In these maladies the manifest local 
disease most commonly affects the skin, but is clearly secondary to 
a specific morbid state of the system. It runs its course and subsides 
spontaneously, and unless in exceptional cases the constitutional dis- 
turbance subsides with it. 

Now, this seems to be the case in the secondary affections of fever, 
whether they be attended with anatomical change or be simply neu- 
rotic, whether the head, chest, or abdomen shows signs of disease. 
This latter is the product of the essential condition — that is, of the 
fever — and not its cause. You may meet cases where but one cavity 
is affected, even throughout the fever, where the three cavities are 
simultaneously engaged, where they are severally attacked, or where, 
in the whole course of the fever, there is no anatomical change. 

Now, what I want you to believe, and what, when your actual ex- 
perience of successive epidemics has been obtained, you cannot help 
believing, is, that as regards these secondary diseases, there is no con- 
stancy in their production — none as to amount, none as to intensity 
— and you may add, as to their combination and even their seat. Im- 
portant though they may be, frequent as certain forms of them are in 
certain epidemics or in certain localities, they may be looked on more 
in the light of accidents than of constant occurrences. 

They may be occasionally so extensive and so intense as that death 
may be probably attributed to them; while, on the other hand, their 
amount may be very trifling, and have no proportion to the severity 
of the general malady. In fact, it is impossible to predicate what 
course the secondary disease may take from spontaneous and some- 
times sudden retrocession to extreme disorganization. Thus the 
affection of the lung may vary from a slight to a dangerous degree of 
bronchial irritation, with congestion, causing extensive and rapid 
consolidation, and even a fatal sphacelus. Or there may be a great 



CONTAGION. 27 

development of tubercle, either confined to the lung or engaging many 
other organs. Again, a rapid consolidation may take place — generally, 
as it were, silently — and attended by a cessation of the fever. We 
shall return to this when discussing the pulmonary complications. 
So also you will find great variations in the nature and intensity of 
the abdominal affections, from slight partial congestion, with or with- 
out deposit in the mucous glands of the intestine, to extreme relaxa- 
tion, softening, and perforation of the tube — it may be in many places 
with or without general acute peritonitis — or, as certain cases in the 
epidemic in 1827, there may be numerous intussusceptions, great con- 
gestion and enlargement, with softening of the spleen ; and, though 
the intestinal suffering be extreme, even without ulceration or per- 
foration of the tube. 

Now, gentlemen, what I wish you to bear in mind is, that the re- 
lation between the anatomical states of organs in fevers is a variable 
one, whether as regards the seat, the combination, the intensity of the 
affection, or the time of its appearance, or its effect on the general 
malady. Every great epidemic of fever, of whatever kind, must be 
studied first separately, and then comparatively, and you will find 
that the history of fever is a much wider subject than you might infer 
from books. 



LEGTURE IV. 

Contagion — Exclusive doctrines are to be deprecated — Endemic disease arises inde- 
pendently of contact — The numerical system of Louis fails in practical medicine — 
Evidence in favour of contagion from the Doctrine of Chances — Investigations of Dr. 
Whitley Stokes and the Bishop of Cloyne ; with Dr. Paget's remarks thereon 
— Variation in the degree of contagiousness of acute essential diseases. 

As I have said, a striking difference of fevers, compared with the 
pure neuroses and the structural diseases, is their contagious nature. 

With regard to this characteristic, medical opinion has been long 
divided ; and I would advise you, as a general rule, not to range your- 
selves among the advocates of any exclusive doctrine. You are not, 
therefore, to stand in the false position of men who are fighting for a 
particular doctrine, whether they be contagionists or non-contagionists. 
Should you do so, your mind will be occupied with the excitement of 
controversy rather than with the search for truth. You will become 



28 LECTURES ON FEVER. 

advocates, while you cease to be inquirers, and once this change occurs 
in the mind of the observer, he loses caste in the ranks of science. 

The advocates of an exclusive doctrine on each side of this great 
question are able to produce many facts in evidence of their particular 
views. The facts thus brought forward may be, and probably are, 
in each case true; but the conclusions drawn from them may not be 
warranted. It would thus be wrong to infer that a disease was not 
contagious from the failure of evidence of its communication even in 
many instances. Equally illogical would be the deduction that a dis- 
ease arose only by contagion, even where multiplied examples of such 
an origin could be appealed to. 

There can be no doubt that disease has originated, and may 
originate, without contagion. This must be obvious to every man. 

Again, we see a vast number of cases in which disease is endemic. 
I need scarcely allude to the common case of ague. There are certain 
districts where ague is constantly produced, and where, if a man who 
has not had ague goes, and is not in contact with any human being 
whatever, he will, almost certainly, get the disease. Here, then, 
clearly, there has been disease independently produced, or at least 
without human contagion. There are certain districts in South 
America and in the West Indies, vast districts on the coast of Africa, 
forest districts in Hindostan, where, if a man sleeps for a single night 
— although we will suppose him to be alone, without any companions 
but the wild beasts of the forest — he will get some form of fever. 
We see also, if we look at the records of medicine, unquestionably 
even within the later periods of the world's history, the appearance of 
new diseases, totally new diseases. So that we cannot at all deny that' 
disease may be generated, and that it may spread without the interven- 
tion of human contagion. We must believe, I say, in the origin of dis- 
eases under some exciting cause; but that exciting cause need not be 
human contagion. On the other hand, innumerable facts show that fever 
existing in the system is capable of being propagated from one man 
to another; that it is, in fact, a contagious disease in the strictest sense; 
and this transmission of the disease may not be merely by contact, 
but by vicinity — within, it is true, a limited space. Now, the facts 
which we must rely on to impress this doctrine of contagion on your 
mind, when you come to examine them, will appear less direct than 
you might suppose. A great number of men who have written on 
this subject were really but ill-instructed in the rules of logic; they 
have not been trained to think properly and argue correctly on the 
subjects they were considering. For instance, it was a great object 
with a number of the French school, especially with the disciples of 



CONTAGION. 29 

Broussais and advocates of the physiological doctrine, to establish the 
non-contagiousness of disease. For the doctrine of contagion implies 
essentiality; and the physiological doctrine was opposed to all essen- 
tiality. According to this doctrine, there was no such thing as essen- 
tial disease. Every disease was local and inflammatory; every fever 
was symptomatic. Therefore, in their anxiety to overturn essen- 
tialism, they found this outwork, as it were, of contagion, which should 
be carried. And nothing can be more singular, or, I may say, heroical, 
than the efforts which a number of the French physicians made to 
establish the non-contagiousness even of the most contagious diseases. 
Many of them went out to the Levant and exposed themselves pur- 
posely to the contagion of plague — put on the clothes of persons who 
were labouring under it; slept in the beds with plague patients; inocu- 
lated themselves with the matter from the buboes of persons labour- 
ing under the disease, in some instances actually inoculated themselves 
with the blood of plague patients. "Well, in many cases these experi- 
menters did not take the plague, and this fact is still relied upon as a 
proof of the non-contagiousness of plague and of fever generally. But 
you will at once see how very inconsequential these experiments are. 
Here are four or five cases of failure of contagion, and as well might 
you argue that corn does not grow from seed because one grain sown 
in the earth will sometimes fail to produce the plant. I may state 
here, however, that some of these investigators paid the terrible penalty 
of death in their zeal for science, for they did take the plague and 
were lost. 

Among the direct facts which satisfy our minds as to the contagious 
nature of fever are the circumstances attending its spread through large 
masses of people. I need hardly here allude to the singularly forcible 
argument in favour of contagion which may be drawn from the frightful 
mortality of our Irish medical brethren in the years of 1847 and 1848. 
This subject I have already alluded to in the theatre of the Meath 
Hospital, and it is one which we can hardly look back upon without 
shuddering. The simple fact alone of the mortality of that class of 
individuals who are most exposed to the disease, furnishes an argu- 
ment in favour of contagion which we would but weaken by any 
observations upon it. 

There is a mode of dealing with the indirect evidence for contagion, 
to which I shall now draw your attention. You all know that Pro- 
fessor Louis, of Paris, founded what he terms the numerical s}'stem 
of medical investigation; that is to say, he attempted to reduce the 
facts of medicine to numerical expression ; so that we should be able, 
as he supposed, to make medicine an almost exact science. My opinion, 



30 LECTURES ON FEVER. 

I may state, generally speaking, on the subject is, that for the establish- 
ment of all that part of medicine which consists in fixing the data of 
physical diagnosis, the frequency or infrequency of certain pathological 
changes and matters of that kind, the numerical system is infinitely 
valuable; but that we cannot, or have not yet been able to apply it 
so as to furnish rules of treatment. For the object of the numerical 
physician and that of the practical physician — if I may make use of 
such a distinction — are different. The object of the numerical phy- 
sician is to ascertain a rule of treatment which will cure the greatest 
number of cases out of a given number; but that should not be your 
object, or that of practical physicians. It is very well to know that 
such results have been obtained; but it does not follow that you are 
to act on them. Your course is not blindly to adopt the formula 
founded on numerical data when it is shown that by its use you can 
cure the greatest number out of a given number; your object is to cure 
the diseases of A, B, or C, as they may come before you. And you 
are not to neglect what you believe to be right in the case of A, B, or C, 
because you have this array of figures declaring to you that such and 
such a course, different from that you may be about to pursue, is the 
rule for saving the greatest number of lives out of a given number. 
But we may safely use numbers in a different way — as, for example, 
in investigating the data of a particular doctrine. 

My father, when Professor of the Practice of Medicine in the Royal 
College of Surgeons, directed his attention very much to the subject 
of contagion. He was a strong advocate of the doctrine of contagion. 
Perhaps he went too far in his belief in the exclusiveness of this 
doctrine. Perhaps, also, he went too far in denying the views of the 
epidemists, or of the non-contagionists. However, that hasxHothing 
to say to the present question. He thought that, in looking at the 
general circumstances which attend the spread of an epidemic in this 
country, the probabilities for or against the doctrine of contagion 
might be submitted to calculation. One of his most intimate friends 
was the late Dr. Brinkley, Bishop of Cloyne, who was at one time the 
Astronomer-Royal of Ireland. He was admittedly one of the very 
first mathematicians of his day, and especially skilled in that difficult 
part of mathematical investigation — the Doctrine of Chances. 

In the progress of an epidemic in Ireland (and doubtless also in 
other countries) in a family of twelve persons the disease has been 
known to attack eleven out of the twelve. In some cases, the passing 
of the fever through so large a proportion as eleven individuals out 
of twelve has taken a very considerable period of time, as you may 
readily understand. It has taken about three months to go through 



CONTAGION. 31 

them all. Now, my father proposed these two problems to the Bishop 
of Cloyne for solution: — 

1st. An epidemic prevails so severely that one person out of seven sickens. 
A family of twelve is selected in a particular district before the epidemic has 
visited it. What is the chance that eleven out of that family will take the 
disease, supposing the sickness of one of the family does not promote the 
sickening of another — that is, supposing the disease not to be contagious, 
and supposing the family to be not unusually liable to the disease ? 

The answer furnished by Dr. Brinkley was, that the probability against 
such an event is 189,600,000 to 1. That is a very singular and extra- 
ordinary result. 

2d. The same general conditions being assumed, and also that the number 
of inhabitants of a district is 7000, what is the chance that in a family of 
twelve within the district eleven will sicken ? 

Answer : The chance then is 300,000 to 1 that no family of twelve persons 
in a population of 7000 will have eleven persons sick. 

These numbers furnish proofs so convincing of the truth of the 
doctrine of contagion, though by no means in an exclusive sense, that 
it is hardly necessary to go further. The facts on which they were 
based are ascertained facts; they have been not uncommon facts in epi- 
demic fever; but, recollecting this, the chances against their happen- 
ing, if the disease were not contagious, would be 189,600,000 to 1 in 
the one case, and 300,000 to 1 in the other. 

On this subject I have had the honour of receiving a letter from Dr. 
Paget, of Cambridge; and I would not be doing justice to you, or to 
the question generally, if I did not state the objection made by this 
eminent physician, as to the soundness of the conclusions in favour of 
contagion, which appear deducible from these calculations. Dr. Paget 
observes that the form in which the problems are stated excludes the 
consideration of all local influences except contagion; in this he is 
perfectly correct. He considers that had this element of local influence, 
besides contagion, been included, it must necessarily have diminished, 
by whatever was its real value, the overwhelming result which the 
calculations, as they now stand, give in favour of contagion. But even 
Dr. Paget himself admits that — taking the case of the second calcu- 
lation — if the consequence of these deductions on the score of local 
causes were to reduce the probability of 300,000 to 1 to that of 1000 
to 1, yet this latter probability would be sufficient to carry con- 
viction to the mind of any candid person. He, however, observes 
that we have unhappily no means of estimating numerically the 
requisite deductions, no means of calculating the effect of noxious 
exhalations from decomposing organic substances, of bad food and 
other assignable causes, which have been supposed capable of pro- 



32 LECTURES ON FEVER. 

moting the spread of fevers ; and be properly remarks that Bishop 
Brinkley's results include, with contagion, the possible effects not only 
of known but also of all unknown causes which may make an indi- 
vidual household more liable to fever than their neighbours. 

While I feel indebted to Dr. Paget for having drawn my attention 
to this point, and to the importance of noticing it, when the numerical 
value of these results is considered, I think it well to mention that in 
my father's " Observations on Contagion" there is nothing which 
would lead one to believe that he advocated that doctrine in an ex- 
clusive sense. His object in proposing the problems was to show the 
great probability in favour of the doctrine of contagion as one and a 
principal cause of epidemical disease, and this irrespective of the 
question whether or not other causes might be held to coexist. The 
result seems to establish the certainty of the existence of contagion 
as an important cause of the phenomena in question. The singular 
array of figures is valuable as establishing the fact that contagion has 
a real existence. The terms of the questions may be held to embrace 
all other possible causes of sickness. My opinion, however, is that 
in Ireland local influences have not that great importance either as 
generators or promoters of fever which some believe them to have. 

We must believe that the causes of fever, independent of mere con- 
tagion, are various in the extreme, that they are probably nume- 
rous and complicated, acting in combination rather than singly, and 
varying in their effects not only in consequence of their own properties 
and combinations, but also as regards the condition of the individual in 
whom fever is developed. Dr. Paget, in observing that our pathology of 
fever is not so perfect as to assure us that there are no exciting causes 
besides those which are commonly allowed, notices the comparative 
immunity of infants and persons above forty years of age from the 
typhoid fever with rose spots, and affections of Peyer's glands, etc., 
indicating that the constitution of the individual is an element in the 
question. 

You are then to understand that, while we believe in the contagious 
nature of fever as an established fact, we do not go the length of saying 
that all cases of fever originate by contagion. In the present state 
of knowledge we must, I think, admit that certain combinations of 
physical circumstances may produce fever, either in a single case or in 
masses of men. It is hardly possible to gainsay this; but it is at least 
as well if not better proved that this fever is capable of being com- 
municated by actual contact, or by vicinity, from one individual to 
another. 

If we look to other diseases which affect the whole economy, we 



CONTAGION. 33 

find analogies between them and fever; so far, at least, that in them a 
morbid condition exists which reveals itself in two ways: one, a state 
of general ill-health; and the other, the production of local and specific 
alterations. Take, for example, tubercle and syphilis. 

The last of these is, at all events, contagious; and though we can 
hardly show any mode of its production except by communication 
from one person to another, yet we must believe that at one time 
causes independent of such a mode of communication did exist, and 
were capable of originating the disease; and it may be that, as the 
world advances, and the general exciting causes of fever are diminished, 
or perhaps removed, this disease too, like syphilis, may only be pro- 
duced and exist by means of its communication from one person to 
another; and we may hope that such a state of things would be a step 
to the extinction of fever, at least as a disease affecting communities 
of men. 

If it be true that we may admit two phases in the history of acute 
essential diseases, one in which they are not only communicable, but 
capable of original production by causes independent of contact with 
the sick, and the other when these latter causes ceased to operate, and 
the disease is reduced simply to a special condition, which can be 
communicated only by contact, it is easy to perceive that, so far as 
prevention and ultimate extinction are concerned, the difficulties 
attendant on the matter will be greatly diminished. Let us assume 
that, so far as the cessation of the operation of general external causes 
is concerned, variola and syphilis are similarly circumstanced, and 
we may hope, from what has occurred with respect to the former dis- 
ease, that a similar diminution of fever may yet be attained, when it has 
at last passed into the condition of a merely contagious disease. 

That almost all cases of acute essential disease are contagious I 
have long believed. The amount or degree of contagiousness varies 
according to many circumstances, such as the nature of the malady, 
the amount of exposure, the physical condition of those so exposed, 
and the character of the epidemic. There can be no doubt that in 
different epidemics — apparently of similar diseases — the character of 
contagiousness varies remarkably, and I am glad to perceive that 
modern British authorities now admit that even typhoid or enteric 
fever may be propagated by contagion. 

"Some physicians," writes my father, 1 " in arguing against the con- 
tagious nature of certain fevers, have ventured on the adoption of a 
principle which appears to me very untenable — namely, that a dis- 

1 Observations on Contagion, p. 25. 



34 LECTURES ON FEVER. 

ease can have but one cause — and hence they infer that the advocates 
of contagion, instead of supposing, as they do at present, that contagion 
is the general cause of fevers, with which famine, filth, damp, or cold 
co operate singly or collectively, should suppose that one only of these 
causes can be the true cause of every particular disease, and that the 
admission that other causes contribute to disease is in fact a confession 
that contagion does not." 

For contagious disease, such as typhus or typhoid, though it may 
occasionally attack individuals of the oppulent classes, runs like wild- 
fire through an indigent and unhealthy population. The power of 
resistance is lessened, and all the evils of the asthenic conditions are 
increased. 



LECTURE V. 



Causes of Fevee — Preventive and Curative Medicine contrasted — Risk of error in 
limiting the number of the cures of disease — The correlation and the convertibility of 
disease two important questions, the answers to which are not as yet fully or satis- 
factorily determined. 

With respect to those causes which may be held to be capable of 
exciting fever, irrespective of contagion, I have only to say that as yet 
we know but little about them; and we have the highest authority 
for believing that the origin of epidemics is one of the most obscure 
and difficult subjects in the whole range of physical inquiry. But I 
cannot help expressing my belief that too much stress has been laid 
upon the effects of miasmata resulting from imperfect drainage, or the 
want of ventilation and of public cleanliness in general. No one will 
for a moment suppose that I wish to teach that these influences do 
not act in deteriorating the physical health and moral condition of a 
people, and in thus increasing the mortality of any existing epidemic, 
and that their removal is not an imperative duty of every government 
and community. 

For some years past great attention has been paid in England and 
on the Continent, especially in Germany, to sanitary science — that is 
to say, to Preventive as distinguished from Curative Medicine. If we 
compare the relative importance of these two great branches of medi- 
cal science, it seems true that a greater value should be attached to 
the first than to the second branch, and for this reason, that the well- 
being of infinitely greater numbers of mankind depends more on 
Preventive than on Curative Medicine. 



PREVENTIVE MEDICINE. 35 

The great end of the former is to preserve the health of the masses 
of mankind so as to prevent or to diminish the necessity of the latter. 
The one is a matter to be dealt with by a large and wise legislative 
code ; the other is dependent on the slow advance of medical science, 
and on the individual character and attainments of those who are to 
carry it out. The one embraces everything, as Dr. Acland has well 
shown, which relates to the physical and the moral well-being of 
nations, 1 the grinding of the poor, the consumption of human life, 
as it were fuel for the production of wealth. 

Selfishness, indulgence, unrestrained vice, and every cause which 
tends to deteriorate the body come within its extended scope. Its 
object is the health and the happiness of our fellow-creatures. Its 
rules are plain and patent to all, and depend not on vexed questions 
of difficult science; so that it promises to be the noblest pursuit open 
to human beings, and he would be a bold man who dared attempt to 
predicate its triumphs or to limit its results. 

The occurrence and the spreading of epidemical disease have long 
engaged the attention of advocates of sanitary reform ; but it does not 
appear that as yet the difficulties connected with these questions can 
be said to have been at all satisfactorily solved, even though the im- 
portance of sanitary measures be frankly admitted. 

The paramount doctrine which has prevailed in England ascribes 
epidemics to want of cleanliness, overcrowding, deficient or impure 
air and water supply, imperfect drainage, and so on; while the cessa- 
tion of local outbreaks of disease after the adoption of a sanitary reform 
is appealed to in proof that the evils in question arose solely from 
removable influences. But the argument is defective — it is like that 
of the therapeutists as regards essential diseases, which run their ap- 
pointed course and then spontaneously disappear. Epidemics of fever 
in this way resemble isolated cases. They also have their periods of 
invasion, of maturity, and of decadence, and the subsidence of an epi- 
demic is in many instances by no means traceable to the adoption 
of certain sanitary measures. The experience of all great epidemics 
establishes this fact. 

There is, however, one theory or doctrine which underlies the whole 
history of British sanitary reform, and this is — that many, if not all, 
forms of endernical or of epidemical disease can be traced to some 
preventable or removable cause, and that by putting a stop to over- 
crowding, and by improving the quality of the water and the air in a 
locality, we may prevent the occurrence of such afflictions. 

1 National Health. By Henry W. Acland, F.R.S., Regius Professor of Medicine in 
the University of Oxford, etc. etc. 1871. 



36 LECTURES ON FEVER. 

I need not here point out to you the tendency which exists in many 
minds to attribute great phenomena to too limited a cause or causes. 
Thus, for example, some form of essential disease arises and spreads 
in a particular locality. This is inspected, imperfect sewerage is dis- 
covered, and the evil abated by the adoption of proper measures. 
Then the sanitarians triumphantly appeal to the circumstances as 
proving that the outbreak was the direct result of the alleged nui- 
sances, and perhaps of them alone. 

By this line of argument many sanitarians of that class who have 
not received a scientific education, and who know but little of the 
history of disease, hold that such unwholesome and removable in- 
fluences may originate diseases which are themselves dissimilar. 

But the question before us is, Are those influences in this country 
the sole or the chief causes of fever? It is difficult to believe that they 
are, because in Ireland, not only in the isolated dwellings of the poor 
which are scattered over the face of the country, but in the towns also, 
all those causes which result from the imperfect drainage of dwellings, 
from the accumulations of decomposing organic matters in their vi- 
cinity, and from imperfect ventilation, are, I regret to say, but too 
constant and too general; and yet the production of fever, whether spo- 
radically or epidemically, is inconstant and irregular in the highest 
degree. Why should these causes produce fever at one time and not 
at another? Why should districts remain for years free, or compara- 
tively free, from fever, while the supposed exciting causes remain in 
full force? or, again, why if the cause be constant, should the epi- 
demic character of the fever vary? We may say, excluding the con- 
sideration of isolated cases, that each epidemic has a special or pre- 
dominant character; thus, the great epidemic of 1826 and 1827 was 
very different from the epidemic which preceded it in 1818, and from 
those which followed it in 1836 and in 1847. It was in the epidemic 
of 1826-27 that we observed the almost universal prevalence of the 
secondary disease of the intestine; perforations of the intestinal tube 
were common; and yet, since that period, such an accident is rarely 
met with, either in the fever itself or during the period of con- 
valescence. It was at that time, too, that those singular and fatal 
cases of yellow fever, to which we shall have to allude, occurred 
intercurrently. In this fever, also, termination by well-marked crisis 
was commonly observed, a circumstance which is comparatively rare 
in the epidemics of maculated typhus in this country. 

I do not put forward these views as in any way original, for Dr. 
Graves long held the opinion, and taught it in this theatre, that 
something more than the effect of local causes, as the term is com- 



graves' views as to causes of typhus. 87 

monly understood, was necessary to explain the occurrence of epi- 
demics in Ireland. Let me read to you a quotation from his seventh 
lecture, one of those devoted to the consideration of fever: 1 "That 
fever, in Ireland at least, depends on some general atmospheric change 
which affects the whole island simultaneously, independent of situa- 
tion, aspect, height above the level of the sea, dryness or moisture of 
the soil, or any other circumstance connected with mere locality, is 
proved by the fact, that when typhus begins to increase notably in the 
Dublin hospitals, we may always rest assured that a nearly simulta- 
neous increase of fever will be observed at Cork, Gal way, Limerick, 
and Belfast. For a considerable period there was a great tendency 
among physicians to refer the origin of typhus, and of almost every 
variety of fever, to malaria or unwholesome emanations from the soil, 
produced by the decomposition of vegetable matter. In Ireland facts 
do not bear out this hypothesis, for, as already stated, when an epidemic 
of fever has become established it breaks out simultaneously in situa- 
tions the most different, and in some where no such emanations can 
be supposed to exist ; thus I have seen a whole family affected in the 
telegraph situated at the summit of Killiney, a mountain formed of 
hard granite; and, indeed, the granite districts beyond Rathfarnham, 
Tallaght, and Killikee supply the Meath Hospital with its worst cases 
of typhus." Further on he observes, " Although ready to allow the 
general improvement of the health of the public from improved drain- 
age, improved habits of cleanliness, and increased comforts, yet I 
cannot admit that in Ireland we 'are to expect any notable diminu- 
tion of fever from the operation of these causes. In making this state- 
ment you are aware that I am opposing the usually prevalent opinion. 
The grounds for my dissent have been partly explained to you already, 
for, according to my observation, the increase or diminution of fever in 
Ireland arises from some unknown general atmospheric or, if you will, 
climatic influence, quite independent of locality, and consequently the 
most improved and thoroughly drained towns and country districts are 
quite as liable to epidemics of typhus as are the most neglected and 
marshy parts of our island. The causes which occasion these epidemics 
are, on the other hand, in no way connected with the notable variations 
of the seasons; for with us the ravages of typhus are observed some- 
times in dry, sometimes in rainy seasons, and its epidemics appear 
quite uninfluenced by the cold of winter or the heat of summer." . 
In Ireland the habits of the poor as to uncleanliness and over- 

1 Clinical Lectures on the Practice of Medicine. Reprinted from the Second Edi- 
tion, 18b'4, p. 62. 



38 LECTURES ON FEVER. 

crowding call for great reform, especially in our towns, where poverty, 
neglect, and overcrowding so often make them foci of endemical 
disease. The condition of our country towns and villages is simply 
deplorable, disgraceful to the local authorities, and in too many in- 
stances to the proprietary, frequently heedless as to the social and 
physical condition of those who live under them. Even the state of 
the metropolis, possessing a Public Health Committee, is shocking, and 
has been ably shown by Dr. Grimshaw in a recent communication to 
the Medical Society of the College of Physicians, Ireland. 1 

What I wish you to believe, gentlemen, is, as I have already stated, 
that our fever is epidemic, proceeding from general but unknown 
causes — and also contagious ; and no one can deny that causes which 
would act in depressing the health and moral energy of a people, by 
rendering them less able to resist the effects of disease, would increase 
the general- mortality. The influence of bad ventilation and over- 
crowding I need not here dwell on; nor, on the other hand, need I 
occupy your time with more arguments to establish the truth of the 
doctrine of contagion. You will find in the writings of Sir Robert 
Christison, of Dr. Murchison, and of Dr. Graves convincing evidences 
on these points; and let me again refer to the great argument drawn 
from the liability to contract fever observed among the medical prac- 
titioners of Ireland, especially in the epidemic of 1847. 

The occurrence of offensive odours proceeding from the putrescence 
of organic matter naturally led to the widespread idea that the ob- 
jectionable smell was the exciting cause of sickness, and that all sani- 
tarians had to do was to remove the sources of air and water pollu- 
tion. But though the researches of Murchison and of Sir William 
Jenner go far to connect what has been called typhoid or enteric fever 
with the existence of noxious emanations from human excreta, other 
weighty questions remain. 

For example, Are these emanations the sole cause of the so-called 
pythogenic or enteric fever? Is this fever essentially different from 
typhus ? Can it be propagated by contagion, irrespective of exposure 
to putresence? Can it originate from the contagion of typhus? Is 
the relation of the local to the general malady the same as in typhus? 
And do the principles of treatment materially differ? Again, we 
must put to ourselves this most important query: Does sanitary 
reform, in providing a supply of pure air, pure water, sufficient drain- 
age, and so on, act by extinguishing the sources of epidemical disease ? 

1 That, notwithstanding, the presence of filth does not itself presuppose the presence 
of fever will appear from the facts relative to certain places in the country districts 
of Ireland, which will he found iu Appendix A. 



CORRELATION AND CONVERTIBILITY. 39 

Or is it that by the consequent improvement of the health of the 
population the community is better able to resist illness, be it con- 
tagious or non-contagious, and to lessen its severity when it does 
supervene? 

This, I apprehend, is, in the present state of our knowledge, the safe 
and practical way in which to regard these all-important questions. 
Civilization demands that all deleterious influences, all that offends 
the senses, should be removed or checked, and the population of a 
country placed under the most favourable sanitary conditions, es- 
pecially as to its supply of air, water, food, and clothing; but the sub- 
ject is a wide one, and embraces far more than the actual origin of 
endemical or even epidemical disease. 

With reference to the presumed origin of that form of fever called 
by Dr. Murchison the Pytho genie Fever, I would warn you, without in 
the slightest degree throwing doubt on the value of his researches, 
not to follow the system of attributing complex phenomena, or states 
of things, to a single cause, or to a too limited number of causes. 

" This supposition of a single cause of the effects we witness is 
quite unsupported by nature. Every animal, every plant, every rock, 
requires for its production the co operation of many causes that we 
know of, and most probably of many more that we have not yet dis- 
covered. All nature depends ultimately upon a single cause, but it 
has pleased that Almighty Cause that the effects which concern us 
immediately should arise from the co-operation of several of His 
creatures." 1 

There is another habit against which I would put you on your guard : 
the one, namely, of holding that every disease of which a description 
appears in our nosologies is a peculiar and isolated entity, separated 
by hard and fast lines from any other either in its nature or in its 
exciting cause. The attention of physicians has been awakened to 
the doctrine of the correlation of zymotic diseases, 2 a doctrine which 
has been long suspected, to be true by practical men. 

Yet, it may be asked, can we not go a step further, and consider 
whether essential diseases are not convertible as well as correlative ? I 
think that before the session is over you will meet with instances 
which will incline you to arrive at both conclusions. Cases will occur 
to you, especially during the prevalence of an epidemic, where the 
disease seems to hesitate as to what particular character it will 
assume, so that it is often a matter of the most extreme difficulty, even 

1 observations on Contagion. By Whitley Stokes, M.I). , p a 25. 

2 Zymotic Diseases, their Correlation and Causation. By A. Wolff, F.R.C.S. Eug. 
1872. 



40 LECTURES ON FEVER. 

when an eruption is well out, to say to which of the exanthemata the 
individual case belongs. Under such circumstances the public used 
to regard it as a mark of ignorance if the attendant were unable to 
give an exact name to the malady, but they are more enlightened now. 



APPENDIX A. 

The following are some extracts of a letter from a gentleman of 
great ability and truthfulness, who holds an important public appoint- 
ment in the South of Ireland. He had been requested by the com- 
missioners of a town in that part of the country to inspect the state 
of the town and report on the works necessary for sewage improve- 
ment. 

It was about the year 1865, when there was some apprehension of 
an epidemic of cholera : — 

"I went," says this gentleman, "through every lane and street, and ex- 
amined all the tenements of every class in the latter end of January or 
beginning of February. There were no main sewers in any but the princi- 
pal streets, and none of these had them for their whole length. The lanes 
and alleys leading off from these streets were mostly very narrow, and- had 
no outfalls for sewerage discharge except surface channels, and very few of 
the houses had any back entrance; a good many had neither yards nor back 
entrances. But all had dung-pits. If not behind, they were contrived in 
the widest parts of the lanes by being sunk and inclosed with walls, so as to 
hold from 8 to 12 cubic yards of manure each. Where the tenement had 
not the 'easement' of a dung-pit or yard, or right to part of the common 
way, the manure was stored in the dwelling house. Most of the houses 
were thatched cabins, but several rows of two-storied houses were built, and 
a good many one-storied slated houses of small size were to be found con- 
taining four apartments. I discovered in one of these rows, which had very 
small backyards (not half the size of the house in any case), that the whole 
of the ground-floor, and part of the house, except the staircase and passage 
leading to it, were filled with manure (the scrapings of the roads and streets) 
tightly packed to the height of eight feet ; and in the rooms above there were 
two families living — one in each room. The manure had of course heated, and 
was steaming up through the chinks of a badly-laid floor, the under side of 
which was dripping wet from the the fermentation below. 

"In several of the rows having backyards the surface water was allowed 
to run through the whole length of the lane from yard to yard, and the 
occupier of the lowest tenement was looked upon as having the most valu- 
able holding of the whole lot, and something like the Chinese care of liquid 
manure was shown by extra mould or refuse being provided to absorb or 
soak it up. The parts of the town to which this description may apply 
covered about 25 acres, and almost every part of that surface was teeming 
with etfluvia from such decayed substances of every sort as are admitted to 
be of the most noxious kind, without any provision whatever for carrying 
off the putrid water which is always to be seen in so wet a climate as this. 

"The population is about 6000, of which two-thirds live in cabins fur- 



APPENDIX A. 41 

nished with the inevitable dung-pit. These cabins contain 700 families at 
the least. The dung-pit averages 10 cubic yards in content, so that on 25 
acres we have at least 7000 cubic yards of fetid matter, with 4000 people 
breathing the exhalation of such an accumulation as could not, I think, be 
found elsewhere in Ireland. 

" But nevertheless this town has always been a remarkably healthy place. 
There is a fever hospital which has not been full since the famine dysen- 
tery in 1847-8, and which is very frequently empty. There is no dislike 
on the part of the poor to go into this hospital, because it is not the work- 
house, so that the few fever cases that do occur arc quickly removed out of 
the crowded houses. 

"It was asked — 'How can such a state of things be? or how can it be 
accounted for that such good public health can exist amidst all this rotten- 
ness giving rise to the miasmata so well known as certain producers of 
fever and cholera?' I suggested that there were two great advantages in 
favour of health, namely: an ample supply of the very best water and 
smoky houses. The subsoil of the town is gravel and sand to a great depth, 
and in this there are many strong springs, the purest water being met with 
at 6 or 8 feet under the surface. The fuel used is all turf, and the blackened 
walls of the inside of the houses showed that the inhabitants lived in an 
atmosphere of peat smoke. I cannot help thinking that such smoke, pos- 
sessing as we know preserving or antiseptic properties, must act as a 
deodorizer and preventive against infection or malaria. 

" I asked one of the occupiers who lived over his dung-heap in an upper 
floor how he could expect to escape death by fever or cholera to himself or 
some of his family (a wife and five children), and his reply was, ' Sure we 
might as well be dead as never to have a bit of dung for the garden.' 

" Some legislator has said that 'Ireland is an anomaly ' — may be the san- 
itary statistics of this town are another proof of this." 

The inhabitants of this town escaped the endemical disease so 
common in other towns of the south of Ireland, perhaps because, in 
addition to the pure water and turf smoke, an intimacy with malaria 
for many generations had at last made them insusceptible to it. 

Dr. Pratt, in a paper read before the Surgical Society of Ireland, 
recently touched upon this same question. After alluding to the 
widely accepted theory of the actual origin of fever, as proceeding 
from the decomposition of animal and vegetable matter, he observes 
that "after an experience of nearly a quarter of a century as an Irish 
dispensary medical officer, it is his firm conviction that these agencies 
alone considered cannot be productive of fever of any type. Were 
it otherwise, Ireland would before this have been depopulated from 
sea to sea. " 

" Among the Irish agricultural classes," he adds, " the farm yards 
are simply the open spaces either in the front of their dwellings or 
close behind, the offices, cow-houses, stables, etc., forming a component 
part of them ; the farm-yard manure carefully heaped, in many in- 
stances up to the very door, and in such a way that it often becomes 
a problem to the perplexed doctor, whose aid is desired within, how 



42 LECTURES ON FEVER. 

to effect an approach (especially when called on in the dead of night) 
without sticking ankle deep in mire or filth, or, perhaps, coming to a 
worse grief in the shape of a souse in a slough of despond. 

"Such is the state of affairs during the winter months. In the hot 
weather of summer the pits from which the accumulated manure has 
been removed to the farm, serve as receptacles for slops and refuse of 
all sorts thrown from the houses. These slops, fermenting in warm 
weather, produce a green stagnant pool. The gases generated show 
themselves as bubbles on the surface, which in due time burst, and, 
of course, discharge their supposed noxious contents in the immediate 
vicinity of the dwelling, with all its inmates, old and young." 

Dr. Pratt observes that, in such places, a case of fever, of any type, 
rarely occurs; the average length of life is high, and illness, except 
common colds and infantile diseases, is almost unknown. 

Even in instances where the peasantry live in a worse condition, 
the cattle, pigs, and poultry occupying the same room, and the refuse 
being swept into a pit close by the fireside, he has found the families 
hale and sound, and strangers to fever. 



LECTURE VI. 

Varieties of Feverrs observed (1) in different epidemics, (2) in the same epidemic, 
and (3) in members of the same family, living under the same conditions— This 
last-named fact is corroborative of the doctrine of the essentialism of fever — De- 
finition of the term epidemic character of fever — Outbreaks of 1818-19, 182G-27, 
and 1847 contrasted — Typhus and typhoid or enteric fever appear to be but species of 
the same genus — Contagiousness of typhoid fever — Dr. Flint's memoir — Principles 
of treatment of fever of any type must be based on an acquaintance with the law 
of periodicity, to which the disease is subject. 

The varieties of fever depend upon diverse circumstances. We 
may take, for instance, the disease in its epidemic character. It may 
be laid down as an axiom that no two epidemics of fever have been 
precisely similar as regards the character and aspect of the disease 
presented to our observation on the two occasions. No doubt in the 
history of a series of epidemics, extending over a space of many 
years, some — nay, many — cases analogous in symptoms, and even sim- 
ilar in their mode of termination and in their result, may come under 
our notice. Thus, if the outbreak of 1880 is compared with that of 
1820, cases will be found recorded in the history of the morbility of 
the former year the counterparts of which, so far as relates to symp- 



EPIDEMICAL DIVERSITY OF FEVER-TYPE. 43 

toms, sequelae, and result, may have been observed ten years before. 
Apart, however, from individual exceptions, when any two or more 
epidemics are taken into consideration, they will generally appear to 
differ widely one from another. 

But not only has this diversity of type and character been noticed 
in distinct epidemics, separated by intervals of time, but even in one 
and the same epidemic numerous cases have occurred, characterized 
by symptoms essentially distinct, and marked by as widely varied 
conditions of the bodily system. In one group of cases there will be 
present utter prostration of strength, and intense depression of vital 
energy; in another group we may observe abundant vitality and 
almost unimpaired muscular and nervous force. In the same epi- 
demic, again, fevers may vary in duration ; one lasting but five days, 
another not terminating till the fortieth or forty-fifth day, or even 
later. Once more, we find infinite variations as to the period of the 
essential disease at which secondary complications will show them- 
selves. In some cases the secondary affections in one or more organs 
may not become developed or apparent until after the twenty-first or 
even the forty-second day of the disease. The seat, too, of compli- 
cations may be in one set of cases the brain, in another the thorax, 
and in a third the abdomen. 

We may trace this Protean character of fever even further. That 
in two epidemics, separated it may be by a wide interval of time from 
each other, the type of the disease, its attendant phenomena, its com- 
plications, its duration, and so on, should vary much was perhaps not 
to be marvelled at. That even in the same epidemic the disease should 
present varying forms and characters is more remarkable, though still 
easy of comprehension. But we can carry our investigations a step 
further, and we shall meet with still more striking results. When 
fever appears in a family, living in some confined situation in a large 
city or town, in a badly ventilated dwelling, perhaps in the midst of 
an unwholesome and densely populated neighbourhood, several mem- 
bers of that family may be struck down by the disease. They may 
sicken simultaneously or one after the other, so that we are afforded 
an opportunity of witnessing the effect of the malady on them indi 
vidually. Under such circumstances it has been observed that a 
marked variety is presented in the condition of the several patients. 
One will have the disease in its severest form, another will experience 
but a mild attack ; some will suffer from protracted fever; others will 
go through an illness of the briefest duration ; one will have petechise, 
another will present no eruption: one will display critical phenomena, 



44 LECTUEES ON FEVER. 

whilst another will recover without crisis of any kind ; one will have 
typhus, another typhoid, or even rheumatic, fever. 

Now this is a most remarkable fact, and one strongly corroborative 
of the doctrine of essentialism in fever. We might a priori suppose 
that where there existed a certain similarity in the physical and moral 
characteristics of persons so closely related by consanguinity, so alike 
in habits from living together, and so uniformly subjected to the 
same mode of life, those persons when exposed to the influence of one 
and the same poison or virus of contagious fever would present one 
and the same type of the disease. 

It is of the greatest importance, gentlemen, that you should devote 
your most attentive consideration to reflections such as these in your 
study of fever, in order that you may be prepared for any exigency 
arising from the varied and complex aspects in which the disease will 
present itself before you — in order that you may be duly armed and 
fitted to encounter the deadly, the subtle enemy you will have to meet. 

The constancy in variability of which I have just spoken in rela- 
tion to fever applies also to all forms of local epidemics. As in the 
case of individuals, so of epidemics, one outbreak of fever will be 
marked by profound prostration of the system, by a loss of strength 
requiring the exhibition of stimulants, while another will present evi- 
dences of a sthenic condition of the patients, calling for an exactly 
opposite mode of treatment. This is what is termed the epidemic 
character of the disease. I remember the fever of 1818 and 1819, the 
equally formidable outbreak of 1826 and 1827, and lastly the great 
epidemic of 1847. If we compare the first with the last of these vis- 
itations, we shall find that they possess many points of resemblance. 
Both were examples of severe typhus fever, both had maculae in 
patches, both were petechial. The epidemic of 1826-27 was of a 
milder but more diffusive type; in it vast numbers were indeed attack- 
ed by the fever, but the great and profound sinking of the system 
which prevailed in the other epidemics I have mentioned was not 
present in this. 

So widely spread was the last-named epidemic (that of 1826-27) 
that at the Meath Hospital we were obliged to have additional accom- 
modation for patients provided. Sheds were built, canvas tents were 
erected, their floors covered with hay, on which the crowds of patients 
conveyed to the hospital in carts were literally spilled out. I have 
seen as many as ten patients lying on the hay awaiting their turn to 
be attended to. In fact, so immense was the number of sufferers that 
it became impossible to bestow medical care upon them all ; indeed, 
a large number of them got no medicine whatever, but all received 



TYPHUS AND TYPHOID. 45 

reasonable care and comfort. Abundance of whey was provided, and 
on this, without any farther treatment, numbers got well through the 
fever — as Dr. Rutty, speaking of the year 1739, quaintly observed, 
" abandoned to the use of whey and Grod's good providence." I 
doubt not that the mortality among those treated after this primitive 
fashion was not greater than that among the patients subjected to 
medical treatment secundum artem. It should be observed that there 
was more of an inflammatory character evinced in this epidemic, the 
skin being hot and dry, the pulse hard and full, etc. 

Fever, you are aware, has been somewhat arbitrarily divided into 
two classes, or placed under two great heads — typhus and typhoid. 
Typhus fever is held to take its origin from the vitiated air and the 
unhealthy condition of body resulting from the crowding together of 
masses of human beings, coupled, perhaps, with neglect of cleanliness, 
absence of proper ventilation, clothing, and food, and the prevalence 
of indolent and disorderly habits. The emanations arising from over- 
crowding, or ochlesis, as it is termed, doubtless predispose in an extra- 
ordinary degree to the outbreak and spread of this form of fever, 
a form of the disease which has received various titles — some from 
its connection with ochlesis, as camp fever, jail fever ; others from the 
peculiar morbid phenomena attending it, as putrid fever (when it dis- 
plays a tendency of the solids to run into decomposition) ; spotted fever 
(from the maculse or spots so frequently observed on the surface of 
the body in this form of disease) ; and others again from its well- 
known formidable character and too often fatal result, as typihus gravior, 
malignant fever, etc. 

Typhus also is regarded as being the more dangerous form of the 
disease, but I am by no means convinced that this opinion is correct. 
There is, however, one reason why this idea should be entertained by 
British physicians ; the epidemics of fever which have been most 
fatal in these countries have been of the typhus kind, whilst it may 
be said that we have had repeated visitations of the typhoid form of 
fever attended with a comparatively slight mortality. Typhus fever, 
when it comes, at once assumes the true epidemic character, whereas 
typhoid more frequently prevails endemically, and with less direct 
fatal results. 

Typhoid, enteric, or pythogenic fever is generally attributed to 
emanations from putrid matter, or, according to Dr. Budd, to the ex- 
posure to contagious matter contained in the evacuations of patients 
suffering under the disease. This contagious matter may be intro- 
duced into the .system either through the medium of the air in ;t gaseous 
form or by means of contaminated drinking water. Typhoid lever is 



46 LECTURES ON FEVER. 

considered to be essentially an epidemic disease ; in other words, it 
may occur in particular situations. The opinion was almost univer- 
sally held that this form of fever was non-contagious, but the adherents 
to this doctrine are becoming less numerous of recent years. If it 
were a fact that typhoid fever was not a contagious disease, we should 
have a marked and important distinction at once established between 
it and typhus, but it is not so. I do not say that typhoid fever is so 
contagious as typhus, yet I will not admit that the former possesses 
the attribute of being non-communicable. I would strongly urge you, 
gentlemen, to be very cautious in admitting the line of distinction 
which authors have drawn between these forms of disease as regards 
the question of contagion, and you may depend upon it that the num- 
ber of diseases propagated by contagion is much greater than what is 
generally admitted. We can found no distinction between typhus 
and typhoid upon the circumstance that one of these fevers, as, for 
instance, typhus, is contagious and the other not. I have long be- 
lieved in the contagion of the non-petechial, or, if you will, the typhoid 
fever of this country. In the epidemic of 1826-27, to which I have 
before referred, and which was essentially an epidemic with the so- 
called anatomical characters of the typhoid disease, we had abundant 
proofs of contagion; and in this very hospital many of our most 
zealous students were at that time attacked with fever. 

It may be here observed, that although this epidemic was one 
essentially of the so-called typhoid form, characterized by absence of 
the symptoms of putrescence, by frequent relapses, by recovery, by 
crisis, and in very many cases by evidences of disease of the intestinal 
glands; yet the attendants on the sick, when they were themselves 
attacked, presented in many cases the symptoms of genuine typhus. 
It was during this epidemic that I contracted typhus fever; and shortly 
afterwards one of my clinical clerks, who had been distinguished 
for his zeal in his attendance on the sick, fell ill. We both had bad 
maculated typhus without any symptoms of dothinenteritis ; in my 
case the disease ran a course of fourteen days; and in neither instance 
was there any relapse. 

A very remarkable instance of the contagiousness of typhoid fever 
has been placed on record by Dr. Austin Flint, of Buffalo, United 
States, in a memoir "On the Transportation and Diffusion by Con- 
tagion of Typhoid Fever," published in 1852. In a small isolated 
community, consisting of nine families, at North Boston, county of 
Brie, New York, typhoid fever had been quite unknown up to the 
autumn of 1843. Indeed, in no part of the county of Erie was the 
disease known to have occurred up to the time mentioned. On the 



TYPHUS AND TYPHOID. 47 

21st of September in that year, however, a young man from Warwick, 
Massachusetts, being on a journey westward, took lodgings at the 
tavern of North Boston, kept by a man named Fuller. He had been 
ill for several days, undoubtedly labouring under typhoid fever. He 
died on the 19th of October at the tavern, which was a place of daily 
resort for the members of seven families, with one exception living 
within a few rods of each other. One family, consisting of several 
persons, was on terms of hostility with the innkeeper, and so all inter- 
course was precluded. Twenty-three days after the arrival of the 
stranger, two members of the innkeeper's family were attacked with 
the disease from which he suffered. Subsequently five other cases 
occurred in this family. In all the other families, with one exception 
already noted, cases more or less numerous were observed within the 
space of about a month from the date of the case first developed after 
the stranger's arrival; and during this period more than one-half the 
population became affected. The family in which no case occurred 
was the only one of the seven which was not brought into direct con- 
tact with the disease. The other two families resided at a distance, 
and seemed to be out of the reach of infection. 

So extraordinary was this outbreak that the popular opinion in the 
neighbourhood was that the head of the family in feud with Fuller the 
innkeeper had poisoned a well used daily by the latter, and by six 
other families, of which five were attacked. That this opinion was 
not correct was proved by a careful examination of the water by two 
leading chemists of Buffalo, when it was found to be remarkably pure, 
" the only foreign ingredient detected being a small proportion of 
saccharine substance, which was explained by the fact that the vessel 
in which the water was transported had previously been used as a 
molasses jug. " 

Typhus, again, is said to be an essential disease, affecting the entire 
economy; whilst typhoid has been looked on as & non-essential, or 
merely a symptomatic affection. The inadmissibility of this view has 
already been, I trust, sufficiently indicated in a former lecture. Tt is 
a doctrine at variance with practical experience; it is a theory quite 
incompatible with observed facts. Owing to the ever-varying nature 
of fever, many of its secondary phenomena may or may not be 
present— we may have typhus without measly eruption or macular; 
we may have typhoid without diarrhoea, rose-spots, or any other symp- 
tom said to be pathognomonic. We are compelled to admit that pa- 
thological anatomy has failed as a means of pointing out any essential 
distinction between these two forms of fever. Anatomy, it is true, 
may reveal to us certain morbid changes and abnormal conditions in 



48 LECTURES ON FEVER. 

different organs in many cases of either typhus or typhoid. But 
these alterations are only the results, not even the necessary or con- 
stant results, of the primary disease; and so they throw no light upon 
the object of our search — a vital distinction between the two fevers. 

Even as regards the presumed causes of the diseases — ochlesis, civic 
miasm, poverty, hunger, or cold — are not the conditions supposed to 
be requisite for the development of typhoid present in cases where 
typhus is generated by overcrowding? Are not filth, putrescence, 
impure water, and foul air probably existent in such a state of things ? 
Do these influences produce at one time pythogenic, and at another 
typhus, fever? Do they excite both diseases at once in the same indi- 
vidual? Does A get typhus, while B, exposed to the very same influ- 
ences, and under perfectly similar circumstances, contracts typhoid? 

The treatment of fever, whether it be typhus or typhoid, is reducible 
to a simple formula, and is essentially the same in both types ofdisease. 
We know of no cure for fever; no man has ever cured it. It is, how- 
ever, curable spontaneously. If you leave it to its own course, it is 
capable of curing itself. It will spontaneously subside. Remember- 
ing the law of periodicity, the great object of the physician should be 
to gain time, preserving the patient from the dangers which threaten 
him, which belong to this special state of life. If he can be kept 
alive to the 14th day, the 21st, the 36th, or even the 60th day, recovery 
will probably ensue. Every day, every hour of existence preserved 
and sustained is a clear gain. The risks that he runs are due to debil- 
ity or to the influence of the secondary affections. We, so to speak, 
cure the patient by preventing him from dying. We endeavour to 
gain our end by combating the exhaustion which threatens to prove 
fatal to him with food, with stimulants, and with tonics. We seek to 
obviate or to modify the dangers of the local diseases by meeting them 
as early as we can discover their presence, bearing in mind the depress- 
ing influence of the general malady. Herein lies the secret of the 
treatment of fever. We watch the progress of the disease throughout 
its varying phases; we meet by judicious treatment, as they arise, 
the symptoms of secondary and local malady; we sustain the system 
as far as practicable; we preserve the sufferer at the least expense to 
the constitution ; and we wait patiently until the hour shall strike 
when, in accordance with the mysterious law of periodicity, the fever 
shall have departed and convalescence shall have begun. 



RESEMBLANCES OF TYPHUS AND TYPHOID. 49 



LECTURE VII. 

Points of Resemblance in the various forms of fever a more practical subject for 
investigation than their distinctions — As regards the principles of prognosis, diagno- 
sis, and the management, various forms of fever lose their separate and individual 
significance — Points of resemblance between typhus and typhoid — The famine fever 
in 1847 — Recapitulation. 

Referring to the last lecture, it may be observed that in these 
days the attention of investigators on fever has been directed rather 
to the distinctions between its various forms than to their points of 
resemblance, and yet it may be asked whether, looking at the end 
and object of the study of disease, the latter consideration is not the 
more important. 

Indeed, the more experience of essential disease a man acquires 
the less value he will attach to the classification of it, at least in these 
latitudes ; for though he will find that the mere nosological distinc- 
tions (as given in books) are abundant, yet the grounds of action in 
practice depend more on the general nature of disease than on its 
specific characters, which, though sufficiently well marked under 
certain circumstances, are not so fixed as to warrant the belief that 
they indicate an absolute speciality in disease. 

This seems more certain in those forms of essential disease which 
are classed under the general head of Continued Fevers, such as 
typhus, relapsing or famine fever, and the typhoid or enteric — the 
pythogenic fever of Dr. Murchison. 

There can be no doubt that in a fever hospital you will see various 
cases not presenting the same characters. One patient is prostrated 
at an early period of his illness, his nervous system much affected, 
the heart weak, and the skin covered with petechial spots, while in 
the next bed may be one with comparatively little of the nervous 
symptoms, without eruption, except a few rose spots on the front of 
the body, and with less prostration ; his condition does not seem so 
alarming as that of his neighbour, but it may be that his disease will 
prove fatal, while in the other case there will be a perfect recovery. 

Between these two cases you may find many other points of differ- 
ence in the history, the exciting cause, the amount of prostration, and 
the seat and apparent extent of local change. You may, if you will, 
call one of them typhus and the other typhoid, pythogenic, or enteric 
4 



50 LECTURES ON FEVER. 

fever. That will do no harm. The name of the disease would be an 
important question if it implied such a difference in nature as would 
call for a complete difference in treatment. But as regards the great 
principles of prognosis, diagnosis, and the management which will 
assist nature in the effort to throw off the disease, they are the same ; 
and. so far these cases, though they may individually differ, yet seem 
to belong to the same family. 

I have said that I hold the study of the resemblances or points of 
agreement among these diseases, to be of more value than that of 
their differences, and for this reason, that the former bears on the 
question of treatment much more than does that of their distinctions. 

Now, remembering that fever is a condition of which it cannot be 
said that there is any certain anatomical character, it may be held, 
even if we confine ourselves to but two forms — typhus and typhoid : — 

First: — that they are both essential fevers, in which the local dis- 
ease is secondary to, and produced by, the general ailment. 

Secondly: — that the general malady is influenced by the laws of 
periodicity. 

Thirdly : — that its symptoms may be modified by the local second- 
ary affections, as to their seat, complications, period of appearance, 
intensity, retrocession, and behaviour under treatment. 

Fourthly : — that in both diseases the local affections are inconstant 
as to seat, period of appearance, intensity, complication, and subsi- 
dence ; varying according to the locality, the duration of the malady, 
the epidemic character, the exciting causes, the habit of body, and the 
influence of treatment. 

Fifthly : — that both may exist, and even run their course, without 
the production of recognizable local disease. This appears to be more 
often true in the case of typhus than of the other forms of fever, yet 
even in the typhoid or enteric fever there is no constancy of relation 
between the symptoms and the local change, and in both the local 
diseases are inconstant in seat, amount, and time of appearance, and 
incompetent to explain the phenomena of the malady. 

Sixthly : — that these local diseases are, like the general affections, 
subject to the law of periodicity — that is, they spontaneously subside, 
sometimes before the disappearance of the fever, at other times after- 
wards. 

But when reactive irritation sets in, various structural changes may 
occur, and the fever originally essential may become more or less 
symptomatic. This we may see in very prolonged cases of typhoid. 

There are yet other points of resemblance, of which the most im- 
portant is that both forms of disease are contagious, though probably 



SPECIES, NOT GENEEA, OF FEVER. 51 

in different degrees. This is now admitted by the best observers. 
Furthermore, there is a species of evidence more often attainable 
in an Irish than a British hospital. You know that we have not 
unfrequently in the wards the whole, or nearly the whole, of a family 
sick of fever. The patients have occupied the same dwelling, too often 
the same room, and they have sickened successively and within short 
intervals of time. It is difficult to believe but that there has been 
a similarity in the exciting cause of disease in all, and there is a 
strong probability that the sickness of one has promoted that of 
another. Now, in this group what do we find ? Is it that the same 
character of fever affects them all ? Nothing of the kind — one patient 
may be in maculated typhus; in another there is no eruption; in 
another the case is typhoid, or the so-called pythogenic or enteric 
fever; and so on among them. Even cases of rheumatic fever may 
occur. But this is not all ; second attacks arise, but these are not 
necessarily — not, I might say, even commonly — repetitions of the first 
ailment or group of symptoms. In the typhus fever patient they may 
be those of typhoid; in the non-maculated there may be abundant 
macula?. In the other cases similar circumstances occur, the second 
attack presenting types differing from the first ; one has a short fever, 
another a long one ; one a complicated, the other a comparatively 
simple attack ; one with predominance of cerebral, another with that 
of pulmonary symptoms, and another with all those of enteric or 
pythogenic fever ; one requiring stimulants in the second attack, 
though there was no failure of circulation in the first; and similar 
differences may be seen as to the remaining complications. 

Do not these facts point to the conclusion that there is but a slight 
tension, so to speak, in the individuality or separate characters of the 
various forms of fever, and that in their essence and from a practical 
point of view they may be looked on as species rather than genera — 
the genus being fever, that condition on which anatomical investiga- 
tions, in the words of Graves, throw but a negative light? I tell you 
— not that you are to look at every case of fever as similar in character, 
in complications — that would be bad teaching, as your experience 
would soon convince you — but that it is a condition much more various 
than you would suppose, were you to form your notions of it from 
books. Its many forms are closely related. The exciting causes of 
one may produce another; the secondary effects have not the con- 
stancy which authors describe in seat, in number, in complications, 
or in effect on the general malady. These forms of disease have all 
two great characters in common — essentiality and periodicity. Why 
they differ in general and local phenomena it is hard to say, but we 



52 LECTURES ON FEVER. 

know little of the receptivity of the living body, the laws of the 
variations of that receptivity, and those which govern its results. 
This department of vital chemistry is still to be worked out, nor does 
the study of the apparent exciting causes of the various forms of 
fever give us much stronger grounds for belief in their essential 
differences. Dr. Murchison, in his treatise on the Continued Fevers 
of Great Britain, a work which is one of the greatest ornaments of En- 
glish medical literature, enters at length into the distinctions between 
typhus and the relapsing or famine fever, and labours to show that 
while the one can be traced to overcrowding, the cause of the other 
is destitution. Yet he admits the observations of Alison, David Smith , 
and Henry Kennedy, which show that in one epidemic, in the same 
family, even from the same bed, both forms of fever have been ob- 
served. In wide-spread epidemics, he observes, we may have at first 
relapsing fever only, then relapsing fever and typhus together, and, 
last of all, typhus alone. "Whatever be the explanation," he says, 
" the circumstance is remarkable; but it does not justify the conclusion 
that the two fevers are identical." 1 And he says further on : " As far 
as I know, the statement remains uncontroverted, that in all cases 
where fever can be proved to have been imported into a locality by a 
single case, typhus has produced typhus; and relapsing fever, relaps- 
ing fever." 

To a great extent the observations which I have offered as to the 
relationship between typhus and typhoid seem to apply to that between 
typhus and the relapsing or famine fever. I think the name of 
" Famine Fever" one of doubtful fitness. In the epidemic of 18A7-48, 
which followed the disastrous famine of Ireland, the contagious nature 
of the disease was too well established, as shown by the terrible mor- 
tality of the members of the medical profession, and of many of the 
country gentlemen. Now, if ever the characters of typhus were 
shown, it was then. Every form of continued fever occurred — in 
thousands of cases — relapsing fever, typhoid or enteric fever, and the 
worst form of typhus that could be seen. All the forms were con- 
tagious, and this, whether the subjects of the disease had or had not 
been exposed to destitution or overcrowding. The truth seems to be 
that, while every separate epidemic has more or less of a common 
character, all great epidemics (at least in this country) may be called 
mixed, so far as the occurrence of individual cases is concerned. All 
the circumstances which we have noted as to the relation of typhus 
to typhoid may be said to occur as to relapsing fever. 

1 A Treatise on the Continued Fevers of Great Britain. Second ed. 1873, p. 342. 



TYPHUS AND RELAPSING FEVER. 53 

Without discussing how much is owing to destitution and how 
much to the attendant overcrowding, whether two epidemic diseases 
run their courses pari passu, or whether the fever, of whatever form 
it may be, has been modified by the previous starvation — let us deal 
with some important facts observed in this hospital in the epidemic of 
1847. 

Although, as might be expected, the number of deaths from famine 
within the precincts of Dublin, as compared with the country districts, 
was trifling, still we had not a few opportunities of observing the 
effects of famine in these wards. Many sufferers from want of food 
made their way into the city, and falling down exhausted in the streets, 
were conveyed by the police to the hospital. They had all a strange 
resemblance. The face — and indeed the whole of the bod}' — showed 
a dusky hue, the eyes were sunken and with little expression, the 
features pinched and marked by a profound melancholy; the surface 
was cool, either dry and shrivelled, or clammy, and in all cases the 
body exhaled a heavy earthy smell. These people were as a rule 
apathetic; they made no complaint, but seemed only anxious to be 
placed in bed and allowed to rest. They asked for neither food nor 
drink. There were no symptoms of fever, and the natural desire of 
all who saw them was to give a generous support. But it was speedily 
found that such a course was a dangerous — it might be said, a fatal 
one. In several cases animal food and wine seemed to act like a deadly 
poison, and even where a more cautious use of nutriment was adopted, 
the patients being fed as infants for days together until the collapse 
seemed to be overcome, the system would, as it were, explode into the 
very worst form of maculated typhus, in which death commonly 
occurred on the fifth day of the fever, and in some cases even earlier. 
And this is to be noted in relation to the reports of the relapsing 
fever as observed at the London Hospital in 1843, where the desire 
for food was general. Similar observations were made in Glasgow 
and elsewhere, and this craving appetite, not alone in the remission 
but in the paroxysm of the fever, is appealed to as evidence that the 
relapsing form of fever is really a famine fever. 

But whether the character of frequent recurrence of short attacks 
of fever be owing to the previous contamination of the system by 
starvation or not, we shall not discuss. Certain it is that relapses had 
been common in our wards after 1830. But to say that the epidemic 
character observed was that of a relapsing fever — 'namely, a short 
fever with intervals of apyrexia — is to give a very imperfect idea of 
the disease. Since then the typical relapsing fever — the five day fever 
— has been often met with, sometimes showing an epidemic tendency. 



54 LECTURES ON FEVER. 

but in very many instances being apparently unconnected with desti- 
tution. I may observe that in such cases enlargement of the spleen 
was common, and that in no case did the exhibition of quinine in the 
intervals of the fever prevent the relapse. 1 

But in Ireland an interesting circumstance in relation to the terri- 
ble famine fever was that, in a few years after the cessation of the 
epidemic of 1847, fever, which For so many years seemed rooted 
throughout the land, gradually disappeared to a singular degree. 
The numerous fever hospitals in the country towns were closed, dis- 
posed of, or otherwise utilized, and I remember a period of several 
years in which our wards were all but empty. We may leave to 
others to speculate on the cause of this. 

About this time the level of Lough Neagh, in the County Antrim, 
was much reduced by arterial drainage, and a large space of marshy 
ground on its shores rendered dry. Fever, which had been long pre- 
valent in this locality, was observed to have become very rare, and 
this was attributed to the drainage; yet it is more likely that the sub- 
sidence of the endemic typhus was but an example of the change 
which had occurred over the whole country. 

Let me recapitulate some of the leading points as to fever which 
cannot be too deeply engraved on your minds: — 

Its essentiality. 

Its contagiousness in various degrees. 

Its existence often independently of local or anatomical change. 

The relation of the local to the essential malady. 

The influence of the local malady upon the general fever. 

The inconstancy as to seat, time of appearance, number, impor- 
tance, and complication of the local or secondary affections, 
and their incompetence to explain or account for the pheno- 
mena of fever. 

The periodicity of these phenomena, seen not alone in the general 
malady, but more or less in the secondary affections. 

The occurrence of more than one form of fever in the same epi- 
demic. 

The speciality in character according to the epidemic. 

The similarity in the principles of treatment of the general malady 
and of the local changes. 

These characteristics will serve as landmarks to you whether you 
have to deal only with an isolated case of fever of any form, or with 
a wide-spread epidemic of thousands of cases, and I believe they will 

1 See Murchison, loc. cit. p. 408. 



NO ANATOMICAL EXPRESSION FOR FEVER. 55 

more or less be found to apply to every form of the disease, and in 
every latitude of the world. Let them be engraved upon your minds. 
It may be necessary to say to the j unior members of the class that I clai m 
no originality in putting them forward. I believe that they existed 
in the minds of most practical and experienced men from the time of 
Fordyce to our own, and are based on their recorded observations. 

Gentlemen, I speak to you, and I have always endeavored to do so, 
less as a teacher than as a fellow student — a senior one of course, but 
still, not as a master, but as a comrade. 

We shall find as we advance in the true method of studying medi- 
cine — which is mainly, the practice of it — that we shall attach less 
weight to the distinctions and classifications of essential diseases given 
in books, instilled into our minds in our student days, and clinging 
to us in the early years of professional life, than to the facts connected 
with their history, resemblances, and treatment. 

Believe me, we shall find this a better use. of our time. 

Medical literature and medical teaching give many lessons not 
written in the book of nature, and, when you stand face to face with 
disease, all such will have to be ignored or forgotten. 



LECTURE VIII. 

Division of Fevers into Essential and Symptomatic — No anatomical expression for 
the disease — Secondary affections of fever — These may, and do, frequently produce 
organic changes — The presence of essential disease invalidates the ordinary rules 
of diagnosis — Illustrations of the truth of this statement — Local symptoms of fever 
are (1) functional or nervous; (2) anatomical, i.e. depending on special anatomical 
changes; (3) secondary inflammatory, i.e. arising from reactive inflammation, itself 
due to the typhous infiltration of some part or organ of the body — Similar symp- 
toms may arise from essentially opposite conditions in disease— Illustrations of the 
proposition that fever is capable of producing local symptoms without organic change. 

Tiie division of fevers into essential and symptomatic is admitted by 
most observers. I showed you that amongst essential fevers we may 
reckon a great variety of diseases. All the exanthemata are essential 
fevers; so also are influenza, rheumatic fever, typhus, typhoid, intermit- 
tent and remittent fevers, the plague, the yellow fever, and I believe 
w<e might also add cholera. 

As I have already said, we may describe fever, without defining it,, 
as being a special morbid state or condition of existence subject to 
the law of periodicity, in which the animal economy is found acting 
under apparently -new laws. In this altered state of life general 



56 LECTURES ON FEVER. 

features common to all or to most cases are observed, but the accom- 
panying secondary phenomena are many and extremely varied. 

Tn my opinion, you may take this with you as the basis of your 
views on fever — that, in the present state of our knowledge, we 
possess no anatomical expression for the disease. We do not know 
why secondary affections are sometimes absent, or at what period they 
appear in various portions of the system. Even with the assistance 
of the microscope no anatomical character of fever is as yet discovered. 

However, although it is capable of destroying life without the pro- 
duction of any anatomical change, we find that fever does frequently 
produce such organic changes, and that these in turn influence the 
symptoms of the malady. 

The secondary affections of fever, from which such changes directly 
arise, are not to be regarded as separate diseases, distinct from the 
essential malady. It would be just as rational to assert that the 
various affections of syphilis — the cutaneous disorders, the periostitis, 
the ulceration of the throat, and so ou — were distinct and separate 
diseases, as to say the same of the secondary and local complications 
of fever. The secondary affections in fever are not its anatomical 
character, for it precedes them and exists without them. 

If such affections are confined to or predominate in the belly, we 
may have tympany, thirst, diarrhoea, and a variety of other symptoms. 
If the chest is engaged, we may have difficult breathing, livid coun- 
tenance and the other conditions resulting from imperfect arterializa- 
tion of the blood. A diseased intestine may cause death by exhaus- 
tion or by perforation, or a secondary bronchial affection or congestion 
of the lung may destroy life by asphyxia — not an uncommon case in 
individuals whose bronchial affection has been taken no note of in the 
early course of the fever. This secondary disease may have been 
long progressive ; it is often overlooked and neglected from its latency, 
and a large number of those cases in which death takes place from 
what is called effusion into the chest, attributed to debility or exhaus- 
tion, are in reality examples of a neglected bronchial affection, recog- 
nized only when it is too late. 

Yet in essential fever we must be cautious in arriving at a just 
estimate of the value of symptoms, referable to either the brain, chest, 
or abdomen. 

The existence of the state or condition of fever invalidates those 
rules of diagnosis which are so important where the essential disease 
is not present. Many sad mistakes in the treatment of fever are 
attributable to ignorance of this fact. 

Suppose you find a man who is not the subject of essential fever 



LOCAL SYMPTOMS OF FEVER. 57 

suffering acute pain in the head, with delirium, injected eyes, rapid, 
hard pulse, and so on; the chances are that the man has arachnitis. 
But let him have such a fever, and this group of symptoms cannot be 
taken as indicative of the existence of local inflammation. You 
would commit a grave error were you to treat this man for a disease 
the presence of which it is impossible to assume from the symptoms, 
just because the man has essential fever. 

Again, symptoms may arise indicating an affection of some part of 
the intestinal canal, and yet the stomach or intestines may be per- 
fectly free from disease. Thus in nosological books we read that a 
hot, dry tongue, preternaturally red and parched, is a symptom of 
gastritis. So it might be if the patient had not fever. But we know 
that in many cases the treatment which would be proper were there 
no fever will not answer now. On the contrary, stimulants will prob- 
ably be required. We give the man brandy, wine, and food, and the 
tongue becomes pale and moist. 

The foregoing remarks lead me to speak more fully of the local 
symptoms in fever. These we find to be of several kinds. One class 
of them may be termed functional or nervous : that is to say, singular 
phenomena of functional alteration occurring without necessary or 
corresponding organic changes. I believe that there are none of the 
great organs of the body which in fever may not exhibit this curious 
class of symptoms. In connection with the brain we have delirium 
constantly as a functional condition in fever; pain also, convulsions, 
coma, and so on. If we go to the thorax we often find cough and 
accelerated breathing without any anatomical change of the lung. If 
we turn to the abdomen, we find many of the symptoms which are 
attributed to anatomical change, yet they may exist altogether inde- 
pendent of it. We find tenderness of the epigastrium, and yet no 
gastritis, no peritonitis, no inflammation of the liver; we find swelling 
of the abdomen, or diarrhoea, without any anatomical change; and so 
we observe that there are none of the great organs that may not 
occasionally exhibit symptoms depending, so far as we can ascertain, 
solely upon functional disturbance. This is the first class of symp- 
toms. 

The next class includes those which are connected with special 
anatomical change. Wc may have this change in the brain, lungs, 
heart, spleen, or in the glands of the intestine. In the lungs we 
recognize it by rale, cough, expectoration, the filling up of the tubes 
with muco-puriforrn matter, and on dissection, by tumefaction of the 
mucous membrane, attended by lividity, vascularity, softening, or 
even ulceration. In the heart we find it accompanied by signs of 



58 LECTURES ON FEVER. 

softening of this organ, generally speaking at first confined to the 
arterial or systemic heart. Many of you are, no doubt, familiar with 
the local changes which occur in the spleen and in the intestine. 

Then we come to the third class of local affections in fever, and 
this is a very curious and important one. The condition of the parts 
here is, as it were, a compound one. The organ is supposed to have 
suffered infiltration of what is termed the typhous matter; it has 
become swollen and enlarged. This is a condition which is capable 
of retrocession, without any consequent injury to the part; but in 
certain cases this retrocession does not take place, or is interrupted 
by actual inflammation of the tissues which are thus infiltrated. 

Thus we have three important classes of local affections, two of 
which, though organic at first, are not inflammatory, but may become 
complicated with secondary or reactive inflammation. * 

There is, I believe, a fourth set of local symptoms, or of local affec- 
tions if you will, in fever, which has not, perhaps, received sufficient 
attention. I think it is extremely likely that, in certain cases, we 
have organs suffering from want of a natural supply of blood, and that 
this is extremely likely to take place as far as the nervous system, at all 
events, is concerned. Any of you that have turned your attention to 
the subject of the fatty degeneration of the heart — so often brought 
before the Pathological Society of Dublin — will recollect that one of 
the most remarkable symptoms of this affection is, that the patient 
is liable to repeated and extraordinary attacks of nervous disease, 
shown by a frequent threatening of syncope, or by apoplectic seizures 
continually repeated, sometimes without consequent paralysis, but in 
other cases with a temporary paralysis. This is an illustration of the 
development of important nervous symptoms, not from fulness or 
congestion of the brain, but from ansamia; and it is one of many illus- 
trations of the great pathological proposition — that similar, or nearly 
similar symptoms, may arise from essentially opposite conditions. We 
know that apoplexy and paralysis frequently arise from hemorrhage 
into the brain ; we find that they also arise from anasmia of the brain. 
In the disease to which I so long directed the attention of the classes 
in this hospital — the typhous softening of the heart — there is a proba- 
bility that the brain, under those circumstances, suffers from anaemia; 
and it may be — though this is a point which has not been sufficiently 
worked out — that some of the extraordinary nervous symptoms in 
fever, to which we can assign no anatomical cause, really proceed 
from an anasmic condition of the brain, the result of a temporary 
softening or weakening of the left ventricle — in fact, that in typhoid 
or in typhus fever there is produced, for a certain number of days, 



FUNCTIONAL LOCAL SYMPTOMS. 59 

the condition which is seen as a chronic state in the fatty degeneration 
of the heart. It requires very little acumen to perceive that if the 
brain is liable to this fourth and curious set of local disturbances, 
other organs may suffer in the same way. I merely throw out this 
for your consideration. But we might inquire whether the tolerance 
of wine in fevers is in any way to be explained by an anaemic state 
of the brain. There are few things more curious than the power 
which is shown by patients in fever of bearing a quantity of wine or 
brandy without intoxication. They will often swallow many times 
more wine than would make them drunk if they had not fever, and 
wine becomes a sedative rather than a stimulant so far as symptoms 
are concerned. Does not this indicate a state of the brain the oppo- 
site in some respects to that of health ? I do not want you to believe 
that all the good effect of wine is derived from its action on the 
weakened heart, for it may be that the direct influence of the stimu- 
lant itself on the nervous matter is the cause; but, whether we take 
one or both modes of action, its effect indicates a condition of the 
circulating and nervous systems the opposite to that of inflammation, 
as we understand the term. 

We come now to think on this important proposition, that the 
condition of fever, or, if you will, the poison of fever, is capable of 
producing local symptoms without organic change. We can easily 
understand the poison of fever producing a general fever without any 
local symptoms, but it requires a good deal of teaching and observa- 
tion to persuade men that the poison of fever is capable of producing 
local symptoms without any organic change. It is quite impossible 
to exaggerate the importance of this proposition as a guide in the 
practice of medicine, for it is because it has not been sufficiently 
accepted — because it has not been engraved upon the minds of medical 
and surgical students — that so much mischief is done in the treatment 
of fever. 

Remember the grand rule — and if you did nothing else for the 
whole of the session but learn it, your time would be well spent — 
that those rules of diagnosis of local diseases which are to be accepted 
as true in cases which are not essential fever lose their value to a great 
degree when the primary disease is such. This applies to the local 
symptoms in connection with the three great cavities. You are not 
to apply the rules of diagnosis drawn from the observation of diseases 
which are not fever to the symptoms in fever, because fever is a special, 
essential state, and has its own conditions and its own rules. And this 
confirms the observation which I made in the introductory lecture, 
that the student, no matter how extensive his education may have been 



60 LECTURES 0"N FEVER. 

in surgery and in medicine outside a fever hospital, has really learned 
only half of his business if he has not studied fever at the bedside. 
In consequence of ignorance of this rule, men having a case of fever, 
with symptoms which, they had been led to believe, in cases not es- 
sential fever, were indicative of local inflammation, at once proceeded 
to treat the case as one of local inflammation. 

The patient on the tenth or twelfth day of typhus fever is watchful, 
delirious, violent, complains of great distress in his head, and so on. 
Well, what does the practitioner do who has not learned this rule ? He 
shaves the head ; he applies ice to it ; puts on a dozen or two of leeches ; 
and what is the result? The result too frequently is, that the patient 
sinks rapidly. The symptoms in this case were not the result of inflam- 
mation of the brain; they were not from hyperemia of the brain. 
There was, perhaps, an exactly opposite state: at all events it was 
not such as to require depletion; the patient was suffering under 
general debility, and he sank under the treatment. This is still a 
common case. I have seen applications of leeches to the head in an 
advanced stage of fever with delirium, almost as certainly fatal as a 
pistol shot through the brain would be. Here let me give you the 
observations of Louis illustrative of the actual value of the symptom 
of delirium as an indication of inflammation of the brain in fever; 
and I may mention here that as Louis' observations were drawn from 
the Continental typhoid fever, they must be considered as still more 
applicable to typhus, because in typhoid fever there seems to be a 
greater probability that the local symptom is more closely connected 
with the local irritation than it is here. He took, in the first place, 
twelve fatal cases of typhoid fever which did not present the symptom 
of delirium. In four of these cases he found redness of the brain, in 
six the brain was perfectly healthy, and in two there was slight cere- 
bral softening. Now let us take his twelve other cases, in which 
delirium was an extreme^ prominent symptom. In many of them 
the patients were violently delirious. In five of these cases there was 
redness of the brain, in rive it was perfectly healthy, in one there was 
slight softening, and in one slight injection. 

Now compare these two sets of results. Where there was no 
delirium four patients presented redness of the brain; where there 
was delirium five presented redness of the brain. Where there was 
no delirium in six the brain was perfectly healthy; where there was 
violent delirium in five it was free from disease. The other cases may 
go for nothing. This result is extremely valuable, as showing how 
very little we can depend upon the symptoms of excitement of the 



INFREQUENCY OF ORGANIC CHANGE. 61 

brain as an indication of inflammation when the patient is in essential 
fever. 

Now let us go to some other organ — take the heart. " Well," you 
will say, "the heart need not be taken, because in most of our cases 
the heart shows a depressed and not an irritated state." But there 
are many cases of fever in which the heart is violently excited, as you 
will have frequent occasion to see. What is the result of dissection 
in these cases of excited heart in fever? There are two conditions 
which, according to ordinarily received notions, should lead you to 
expect irritation or inflammation of an organ: first, that the patient 
has fever, and next that you have an organ in a state of great excite- 
ment. If the patient had not typhus or typhoid fever, but had rheu- 
matic fever and an excited heart, the chance would be that that organ 
would be found in a condition of inflammation. If a man has typhus 
or typhoid fever, and his lungs are excited, we find bronchitis or 
pneumonia; if his pleura is excited, we find pleuritis, and so on. But 
here is a case of typhus fever with extraordinary excitement of the 
organ, and when you come to dissect the parts you find the heart per- 
fectly healthy — not the slightest sign of disease is found — and the 
same observation will frequently apply to the digestive system. You 
will have tenderness on pressure of the abdomen, extreme thirst, 
nausea, and vomiting. Yet on dissection the mucous membrane will 
be found pale, and there will be no sign of disease. 

Again, take the eye. Delirium ferox with an injected eye is the 
expression of inflammation of the brain where the patient has not 
essential fever. But take a case of typhus or of typoid fever, and is 
the injected eye a sign of cerebritis? Certainly not. It is merely to 
be looked on as a local affection under the dominion of the general 
disease. The truth is that disease of a really inflammatory character 
is the rarest thing possible in typhus or typhoid fever ; it is so rare that 
many do not believe that it ever occurs. Apply this axiom, then, to 
treatment, and see what becomes of that doctrine which advocates 
bleeding in fever, which advocates starvation and purging, and forbids 
the use of wine and other stimulants. There is another very impor- 
tant view or argument to be referred to here, which all practical men 
will understand. If fever was a group of inflammations, or if it was 
symptomatic of any one inflammation — in other words, if it was an 
inflammatory disease — we ought to expect that in the larger number 
of patients who had gone through the process of fever chronic dis- 
eases of organs would be developed. If a patient has acute rheu- 
matism, we find that his heart may become engaged. He recovers 
from the rheumatism, and then he often has a progressive organic 



62 LECTURES ON FEVER. 

disease of his heart. When you reflect upon the extent of fever, the 
great number of persons that have been at some time in their lives 
attacked with fever, you should at once come to the conclusion that 
if those fevers were examples of groups of local inflammations, we 
should have a much greater quantity of organic local diseases conse- 
quent upon them : but what is the fact ? The fact is that such acci- 
dents are extremely rare. How few cases can be adduced of confirmed 
mania as a consequence of fever. How few cases can be adduced of 
paralysis, of apoplexy, or of hydrocephalus as a consequence of fever. 
Surely if in this enormous number of Gases of fever with violent head 
symptoms there had been inflammation of the brain, in some of them, at 
all events, we should have as a consequence progressive disorganiza- 
tion of the part. 

Again, take the thorax. How few instances are there on record 
of chronic progressive pneumonia after fever; how few of chronic 
pleuritis; how few cases of atrophy of the lung; how few of ana- 
tomical changes which end in progressive organic disease, which has 
started from an inflammatory disease that took its origin pending a 
fever. Go to the heart. We have two classes of heart affections in 
fever — one a softening and weakening of the heart, and the other an 
excitement of the heart. I do not care which of them you take. Do 
we find that, after a recovery from fever, in persons who have had 
either of these affections of the heart during fever, there is a liability 
to valvular disease, that there is a liability to hypertrophy of the 
heart, that there is an adhesion of the pericardium? Nothing of the 
kind. The fact is that those organs have never been in a state of in- 
flammation. They have suffered pending the fever, and the fever 
having terminated, the organs are restored to their normal condition. 
This is a very important consideration, and you may extend it still 
further. If fever was an inflammation of the bloodvessels, it is not 
to be supposed but that we should have many cases of disease of the 
aorta in the thousands of persons who have gone through fever. 
Yet we find no such results. If we go to the digestive system (and 
this is, perhaps, the system of all others which is most liable to 
organic change — at least in the Continental fevers), how few cases do 
we find — or have we any case to show — of chronic peritonitis as the 
result of fever? Not one that I know or ever read of; and yet the 
patient may have had symptoms of severe irritation of the abdomen 
pending his fever. In fact, all that we know of disease of the peri- 
toneum in connection with fever is simply that, in certain cases of 
ulceration of the intestine, a solution of continuity of the peritoneum 
takes place, the fecal matter is effused into the cavity, and the patient 



ILLUSTRATIONS OF THE ARGUMENT. 63 

dies of acute peritonitis. But that does not touch the argument. 
"Where are the cases of chronic diseases of the liver springing out of 
typhus fever ? It has been long a portion of medical doctrine — it 
has become traditional — and everything that is traditional in medicine 
is to be respected — that fever has a depuratory effect on the system. 
Now, whether it has such an effect or not we shall not here inquire ; 
but the very fact of the existence of that doctrine, which is much 
older than pathological anatomy, implies, at all events, a general 
belief that fever does not necessarily lay the foundation of permanent 
damage to organs ; for if it did damage the various organs that exhibit 
local symptoms in the course of the affection, we should not have the 
doctrine of its depuratory effects established. The cases of a chronic 
ulcerative condition of the intestinal tube might be adduced in oppo- 
sition to these views, but I do not place very much weight upon 
them. We may divide them into two classes ; in the one diarrhoea 
or some other symptom is established during the fever, which latter 
runs on indefinitely — here the typhous disease of the mucous glands 
has been attended with reactive irritation, and this has interfered with 
the action of the law of periodicity — so that the fever runs on in- 
definitely. In the next case the fever may be supposed to have 
ceased, but so much disorganization has occurred that the ulcerative 
process seems to go on as it might be supposed to do in another case 
where no typhus had preceded it. 1 

1 The cases related by Dr. Cheyne in the first and second volumes of the Dublin 
Hospital Reports appear to be examples of this form of disease. He describes them 
as follows (vol. i. page 29) : " In these cases the distress of the patient often bore 
no proportion to the dauger he was in ; the former was very little, while the latter 
was extreme. The disease would proceed without violent symptoms — nay, a patient 
would seem to be recovering, although without any critical discharge : he would call 
for full or middle diet, and for days would take his food regularly. The only circum- 
stance in his situation which demanded attention was that he regained neither flesh 
nor strength ; he expressed no desire to leave his bed. Then his pulse became quick 
and his tongue dry, and he would complain of dull pain or uneasiness in his belly, 
attended with soreness on pressure, and a degree of fulness in the upper part of the 
abdomen ; the fulness was not elastic nor hard, nor indeed was it considerable. 
Then came on a loose state of the bowels and great weakness : probably at the next 
visit the patient was lying upon his back, with a pale, suuk countenance and a very 
quick, feeble pulse, his mind without energy. Then the stools (mucous) passed from 
him in bed, and the urine also; perhaps a hiccup came on; next his breathing 
became very frequent, in which case death was at no very great distance." 



6i LECTURES ON FEVER. 



LECTURE IX. 

Local Changes in Fever are symptomatic, subject to law of periodicity, and probably 
depend on the presence of a specific typhous deposit — This deposit possesses a 
vital, specific character — Illustrations of this statement — The principal pathologi- 
cal conditions in fever are (1) functional, (2) intercurrent, and secondary irritations 
of (a) mucous membranes, (&) parenchymatous structures, (c) serous membranes, 
(3) secondary irritations associated with typhous deposits, (4) independent typhous de- 
posits, (5) reactive inflammations, due to these deposits, (6) softening of organs — 
Effect of locality in determining the seat of secondary affections of fever — Effects of 
social rani: in the same direction — Prognosis unfavourable and treatment by stimu- 
lation so far contra-indicated iu cases where nervous symptoms preponderate. 

In the immediately preceding lecture we have seen that the presence 
of local symptoms during the course of an attack of fever does not 
necessarily imply or foreshadow the occurrence of any known ana- 
tomical change. To learn this point is to advance a great way in our 
knowledge of fever and of its treatment. On the other hand, obser- 
vation during life sand post-mortem inspection prove that local diseases 
involving alterations of structures — such as thickening, softening, 
vascularity, effusions, ulcerations, and gangrene — may be produced 
in various organs during the course of a fever. 

Now, the great point in practice relating to these changes is, that 
they are symptomatic of the fever, secondary to the fever, and, in all 
probability, under the same law of periodic action as the general 
malady itself, at least so long as they remain uncomplicated with in- 
flammatory reaction. They do not appear to begin with the fever, 
but they arise after it has existed for a certain time. There is the 
greatest variety in the period of their occurrence, and in their combi- 
nations; they may, as I have just now said, spontaneously subside 
with the fever; they may interfere with its critical termination ; and, 
in certain cases where this does not occur, and when the general 
character of typhus disappears, progressive disorganization may go 
on in the structures which have been already affected. 

In what way are we to consider the nature of these secondary 
affections in fever? It appears now pretty well established that in 
the follicular intestinal disease of the Continental fevers there is a 
special typhous deposit which, at least in the cases of recovery, is 
under the law, first of a progressive, and then of a retrogressive influ 
ence ; just as in variola we observe the progressive maturation and 



SPECIFIC TYPHOUS DEPOSIT. 65 

absorption of the pustule. Eecent pathologists have applied this 
principle to many other of the local diseases in fever ; and although 
the existence of a special deposit is not yet so well or so fully estab- 
lished in the case of thoracic and cerebral complications, or at least in 
the case of parenchymatous as compared with membranous struc- 
tures, still we may believe that an action analogous to that which 
occurs in the glands of Peyer and Briinner, though perhaps not so 
apparent, is developed in all the secondary diseases of fever which are 
not purely functional. 

In speaking of a specific deposit in the secondary diseases of fever, 
I do not wish to convey to you the impression that this deposit 
presents any definite characters whereby it can be distinguished from 
other morbid products; for, even with the aid of the microscope, we 
cannot discover any special distinctive characters in the deposit found 
in the follicles of the intestine, or in other forms of the secondary 
affections of fever. It was at one time believed that the so-called 
" massa typhosa" did present special histological elements; .but more 
recent research has shown that these views are erroneous. Still it is 
possible that, although we cannot determine the existence in it of any 
specific physical character, it yet possesses a vital specificism. Let us 
illustrate this by referring to two specimens of pus — one taken from 
the pustule of variola, the other from an ordinary abscess ; histo- 
logically they will appear similar, yet that they have different vital 
characters no one can doubt. But other conditions are found associ- 
ated with this typhous deposit, or occurring when we cannot demon- 
strate its existence. Under this head we class many of those 
appearances described as inflammatory — such as redness, softening, 
tumefaction, and so on. 

Some have supposed that these states indicate a reactive inflamma- 
tion, and that such does often occur, especially in the intestine, is 
abundantly proved by the researches of Eokitansky and various 
authors. I think it, however, extremely probable that in certain 
structures or organs — as, for example, the lung — these appearances 
of inflammation may precede or accompany the typhous deposit, or 
that they may occur even without such a deposit at all; and I think 
it likely that the liability to actual deposit is much less in the lung 
than in the intestinal glands, and greatly less in the brain and nerves 
than in either the thoracic or the digestive systems. Were it other- 
wise, typhous and typhoid fever would be more fatal diseases than 
they are, death being produced in the one case by coma, and in the 
other by asphyxia. 

But, even though upon a close dissection we may not find anything 
5 



66 LECTURES ON FEVER. 

beyond the recognized appearances of inflammatory action of the 
mucous membrane, we are to believe that this condition, just like 
the typhous deposit, is secondary to the fever, and partakes of its 
specific character. It is not a simple idiopathic inflammation, nor is 
its existence to lead us into the errors of the antiphlogistic school- 
This condition, however, although specific and secondary, has still 
some characters of irritation, or inflammation if you will; and this 
fact points to the adoption, in certain cases, of a practice which, to the 
mere theorist, appears inconsistent — namely, the use of local depletion 
to relieve the suffering organ, while at the same time we employ a 
general tonic aud stimulating medication. 

Let me now indicate to you the principal pathological conditions 
with which, in the treatment of a case of fever, the physician has to 
deal. 

First. We have those remarkable functional derangements which 
are unaccompanied by any known anatomical changes. They may 
occur in relation to any of the organs : but they are, perhaps, more 
important and certainly more frequent in the nervous than in the 
respiratory or digestive systems, at all events in typhus. 

Secondly. We meet with intercurrent and secondary irritations or 
inflammations affecting principally the mucous membranes, less fre- 
quently the parenchymatous structures, and still less frequently the 
serous surfaces. These irritations, although not associated, so far at 
least as we can discover, with any special deposit, are nevertheless of 
a specific character, and under the influence of the laws which govern 
the general disease. 

Thirdly. We have the conditions now specified associated with, 
though probably for a short time preceding, the typhous deposit, just 
as we see in variola the vascularity of the skin often preceding and 
accompanying the vesicular eruption. 

Fourthly. We may observe the typhous deposit occurring indepen- 
dently of any other alteration, and apparently not associated with any 
irritative process. 

Fifthly. We observe the reactive inflammation supervening on the 
typhous deposit — a condition which has been so well described by 
Rokitansky, and which may produce progressive ulcerations, abscess, 
or even sphacelus of the affected parts. 

Lastly. There is a condition of softening of organs, upon the nature 
of which we have as yet no very definite ideas. In some instances 
it seems to be produced by an interstitial deposit of typhous matter, 
while in others it is difficult or impossible to prove the existence of 
such a deposit. This state of softening, as we shall presently see, is 



VARIATION OF SECONDARY AFFECTIONS. 67 

one of great practical importance. Its influence upon the heart, as 
you all know, is most remarkable. Its existence in that organ de- 
mands special attention, and there is good reason to believe that the 
same state, when affecting others of the involuntary muscles — such as 
those of the air tubes, and perhaps of the intestinal canal — has an 
important influence on the symptoms and progress of the disease. 

I trust that, having followed me in the foregoing considerations 
as to a few of the pathological conditions of fever, you are now in a 
position to examine more closely some of the most remarkable local 
or secondary affections that may occur in the course of an attack of 
essential fever. 

In their seat, if not in their nature, these affections are observed to 
vary in different countries. On the Continent — at least in France, 
and throughout a large portion of Germany — the frequency, and prob- 
ably the preponderance, of the secondary disease of the intestines is a 
fact that must be admitted. So remarkable, indeed, is the predomi- 
nance of the tumefaction and ulceration of the mucous glands of the 
intestine in France, that Andral, in the first edition of the Clinique 
Medicale, described fevers under the general head of diseases of the 
digestive system ; and yet Andral was no blind follower of Broussais. 
In Ireland, however, we do not find this remarkable preponderance 
of the secondary diseases of the digestive system ; but when I make 
this statement I wish you to understand and to adopt this principle 
that all descriptions of the anatomical characters of fever, as it prevails 
here or elsewhere, are to be accepted only so far as they apply to the 
prevailing epidemic. And although it is true that, on comparing the 
French typhoid fever with our typhus, the existence of follicular dis- 
ease of the intestine appears to be almost the rule, and its absence 
the exception in the former affection, while in the Irish typhus this 
condition of the intestine is rare, you must bear in mind that in 
Ireland, in our own time, we have had a great epidemic of what was 
certainly typhus fever, in which the condition of the intestine accu- 
rately represented that which is found to prevail on the Continent. 
This is an important fact, and one which some of the Continental 
writers on pathology do not seem to be aware of, or they would not be 
so apt to adopt arbitrary distinctions and positive opinions on the 
matter. In the epidemic of the years 1826, 1827, and part of 1828, 
disease of the mucous glands of the intestine was sj frequent that its 
existence might be held to be the rule, and its absence the exception; 
and it is also true that intestinal ulcerations have been repeatedly ob- 
served in maculated typhus of Ireland, their amount and frequency 
varying with the epidemic influence. Let me refer you again to 



68 LECTURES ON FEVER. 

Dr. Cheyne's papers in the first and second volumes of the Dublin 
Hospital Reports. 

Similar observations have been made in Scotland also. What, then, 
shall we say of that doctrine which declares that there is an essential 
distinction or difference, marked by pathologico-anatomical characters, 
between the Continental fever and our typhus, or between the con- 
tinued fever of Great Britain and fever as we have it in Ireland? — a 
difference to be expressed in this way, that in the Continental or in the 
British continued fever there is extensive ulceration of the intestine, 
while in the Irish fever this condition is wanting. Dr. Lombard, of 
Geneva, whose experience of fever in this country was manifestly 
insufficient to justify his coming to any decided opinion on the subject, 
holds that we have in Great Britain and Ireland two different fevers, 
one highly contagious, which he calls the Irish typhus, and in which 
cephalic symptoms predominate to the exclusion of abdominal ulcer- 
ations ; the other sporadic, and most likely not so infectious, in which 
the abdominal symptoms are more pronounced, so much so that the 
follicular disease and consequent ulceration are always present. These 
two fevers are, in the opinion of this writer, to be found in most parts 
of Great Britain ; but the first is most prevalent in Ireland, and in 
places whither the Irish come in great numbers; the other, similar to 
the European sporadic fever, is met with in all places, varies with the 
seasons, and is not necessarily produced by, or under the influence 
of, contagion. Had Dr. Lombard been aware that ulcerations of the 
intestine are frequently met with in our petechial typhus, and, again, 
that the typhoid fever, or at least a fever with extensive dothinenteritis, 
has raged epidemically for two years in this country, he would have 
been slow in venturing to settle the question in so decided a manner; 
and I have before mentioned to you that during the prevalence of 
any particular epidemic in this country we meet with cases agreeing in 
all their general characteristics, and having the distinctive marks of 
typhus; in one set of which follicular ulceration is met with, while 
in another it is absent. 

If, however, we inquire what are the diseases secondary to typhus, 
for the removal or modification of which we are most often called on 
in the wards of a fever hospital, especially in the worst cases of pete- 
chial typhus, I would say that it is the pulmonary rather than the 
gastro-intestinal complications. Certainly the secondary disease of the 
bronchial surface is often the most formidable of the local affections 
in our Irish typhus. So great, indeed, is the frequency of this com- 
plication, that long before I was aware of the opinions of Rokitansky 
on this point I frequently suggested in my lectures whether the sec- 



BRONCHIAL AFFECTION OF TYPHUS. 69 

ondary bronchial disease might not be held to stand in the same 
relation to the Irish typhus that the follicular disease of the intestines 
in France bears to the fever in that country. Let me read to you a 
passage from Rokitansky's work, translated by Dr. Day for the ori- 
ginal Sydenham Society, bearing on the points before us. He speaks 
as follows of the effect of the typhous process on the mucous mem- 
brane of the air passages: "In primary bronco-typhus the general 
disease originally localizes itself here, avoiding all other mucous mem- 
branes, even that of the intestine, for which in general the typhous 
process shows the most decided preference. The latter mucous mem- 
brane exhibits, however, in many cases a recognizable though always 
subordinate and secondary development of the follicles, in which the 
adjacent mesenteric glands participate, and in such cases it is very 
often a difficult matter to distinguish the typhous element in the 
above-named affection of the bronchial mucous membrane. The 
peculiar stasis of the spleen and of the great cul de sac of the stomach, 
the remarkable intumescence of the former, and the singular charac- 
ter of the blood, the typhous nature of the general disease, and es- 
pecially the altered condition of the bronchial glands invariably serve, 
together with other symptoms, to indicate the typhous nature of the 
bronchial affection. The alteration occurring in the bronchial glands 
is of the same character as that affecting the mesenteric glands in 
abdominal typhus. They become swollen to the size of a pigeon's or 
even of a hen's egg, are of a dark violet colour, which afterwards becomes 
lighter, present a relaxed and friable appearence, and are infiltrated 
with a medullary typhous matter. Like typhous mesenteric glands, 
they may become the seat of a tumultuous metamorphosis, and thus, 
either with or without perforation of the adjacent mediastinum, may 
give rise to pleurisy. This form is often combined with pneurno- 
typhus and typhous pleurisy, and is beyond all doubt the basis of 
the spotted contagious typhus, and very probably also of the Irish 
and North American typhus, forms of the disease which in the 
majority of cases run their course without any intestinal affection. 
With us this affection is rare, and in point of frequency is not to be 
compared with abdominal typhus." 

I may here observe that by the term " tumultuous metamorphosis" 
is implied the occurrence of violent symptoms with suddenness and 
rapidity of progress. Dr. Day remarks that Rokitansky has used the 
term in a new sense, but it means generally — as I understand it — that 
a violent and reactive inflammation occurs in the parts altered by the 
typhous process, which may cause great congestion, turgescence, per- 
foration, or even gangrene. As Rokitansky does not indicate any 



70 LECTURES ON FEVER. 

distinctive features between the spotted contagious typhus and the 
Irish and American typhus, we may safely hold them to be the same 
disease. 

With respect to the question of the comparative frequency and 
importance of the pulmonary as contrasted with the nervous symp- 
toms in fever, as it affects the lower and upper classes in this country, 
my impression is — taking the experience of a long series of years — 
that the secondary bronchial or, to speak more generally, the pulmo- 
nary complications are much more frequent and dangerous in hospi- 
tal than in private practice. It is not easy to explain why this should 
be so, but certainly we find a greater preponderance of nervous 
symptoms in the typhus fever as it affects the upper classes of society 
than in cases of the disease as we meet with it in hospital; while in 
hospital practice the nervous symptoms, though we cannot say that 
they are absent, less frequently require special interference. No 
doubt we meet with coma, delirium, and subsultus tendinum occa- 
sionally, but the predominance of nervous symptoms in the early 
periods of typhus which is so common in the upper classes of society 
is less often seen in our wards; and if you will reflect on the simple 
fact that we so rarely have to shave the head among our hospital 
patients, you will see the truth of what I say. Remember, too, how 
many cases we have had in which, while all the symptoms of typhus 
— such as prostration, weakness of the heart, eruptions of maculae 
and petechias, and well-marked secondary diseases of the mucous 
membrane of the intestines — were present, the patients' minds re- 
mained nearly unclouded, and no symptom occurred calling for any 
special measures directed to the head. The typhus of Ireland, then, 
is not characterized, as Dr. Lombard has described it, by a preponde- 
rance of cephalic symptoms, at least when it occurs in that class from 
which he supposes the best specimens of the disease to be drawn. He 
is as incorrect in his statements about the predominance of cephalic 
symptoms as when he says that the absence of follicular ulcerations 
of the intestines is a distinctive murk of Irish typhus. 

In the typhus fever of the upper classes in this country the ner- 
vous symptoms are generally much more aggravated and developed 
at an earlier period ; and it may be that this preponderance of the 
nervous symptoms, this tendency to affections of the brain in one 
class, even though these affections be principally toxic and func- 
tional, is a cause of the comparative exemption of such cases from the 
secondary bronchial disease. As you advance in the study of general 
pathology, you will find plenty of examples in which diseases of 
structure or of deposition are suspended or replaced by purely ner- 



INFLUENCE OF SOCIAL RANK. 71 

vous affections. Explain it as we will, the general proposition appears 
true that the nervous symptoms, comparatively speaking, are less 
developed in the fever of the lower classes, while those indicative of 
disease of the mucous membranes are much more prominent ; and 
conversely that in the upper ranks symptoms indicative of irritation 
of the mucous surfaces are less prominent, while the nervous symp- 
toms are severe; and this, perhaps, may throw some light upon the 
doctrine, which has been long held by many, that the mortality of 
fever is greater in proportion as we. ascend in the scale of society. 

I have already told you that, as regards prognosis, the preponder- 
ance of any of the nervous symptoms of fever should cause us more 
apprehension than that of any other class of symptoms, and especially 
when this preponderance is observed in an early period of the disease. 
This greater susceptibility of the nervous system in the higher classes 
may itself be a cause why we cannot use wine with as great liberality 
in this -class as with ordinary hospital patients. And this, again, may 
explain the greater fatality in private practice, inasmuch as, in conse- 
quence of the excitement of the nervous system and the frequent in- 
capability to bear stimulants largely, we are debarred from the use 
of that which is the great medicine in fever. 

I think we may lay it down as a principle that the more the sec- 
ondary affections of fever are anatomical, the greater will be the utility 
of stimulants; and conversely the more they are functional, and espe- 
cially in cases where these symptoms are more closely related to the 
cerebro-spinal centres, the less will be the efficacy of wine. It might 
be supposed, from a priori considerations, that the man in the higher 
classes of life who has been accustomed to the use of wine would 
require it more and derive greater benefit from it in the course of a 
fever, which — it must be remembered — is a disease of debility and 
prostration, than the peasant who has not been habituated to the reg- 
ular use of stimulants; but I believe that the very reverse is the fact, 
and that the greatest triumphs of the stimulant treatment in fever are 
to be found when it affects the agricultural peasant, whose nervous 
system has not been excited either by the use of stimulants or by 
intellectual exertion. I know that some will object to this on the 
ground that our Irish peasantry are habitually intemperate, but this 
charge of intemperance is only one of the many erroneous statements 
put forth with reference to our countrymen. 

The Irish peasant is not habitually intemperate — neither do his 
means permit nor his inclinations lead him to be so. When he does 
indulge it is on special occasions, but in hospital we seldom meet a 
case of injury to the geueral health produced by a course of intern- 



72 LECTURES ON FEVER. 

perance in the peasant. The case is no doubt different in the class of 
artisans who are the inhabitants of our large cities and towns. In 
this class we find that when fever attacks an individual we can neither 
use stimulants with the same boldness nor reckon on their success 
with the same confidence as among the more sober classes of the popu- 
lation. In this respect the Irish are not peculiar. 



LECTURE X. 

Secondary Bronchial Affection of Fever — Pneumotyphus of Rokitansky — Views of 
this author as to the anatomical expression of typhus and typhoid respectively — 
Description of the bronchial affection of fever ; frequent absence of symptoms 
therein — Rales sonorous, mucous, or crepitating ; no increased sonority — This 
affection is not ordinary "bronchitis;" it comes on silently and subsides sponta- 
neously — Argument from the effects of treatment by stimulation — Modes of termin- 
ation of the affection. 

In our inquiry into the secondary affections of fever we shall have 
to consider manifestations of disease in the lungs, which have so strong 
a claim on our attention from the frequency of their occurrence and 
the important results by which they are followed. We will take up 
the subject of the bronchial affection of fever in the present lecture. 

This affection is so frequent and common in maculated typhus that 
Rokitansky proposed to found a momenclature for the various forms 
of fever in accordance with the most striking secondary diseases 
characteristic of them. Thus he designated typhoid as typhus abdorn- 
inalis, and maculated typhus us pneumotyphus. He considered that, 
whilst typhoid affected the intestinal mucous membrane as its second- 
ary anatomical result, typhus, on the other hand, engaged the pulmon- 
ary tissues ; that " as the anatomical expression of typhoid fever was 
intestinal ulceration, so the anatomical expression of typhus was dis- 
ease of the mucous membrane of the chest." 

Now, in making statements such as these the great German patholo- 
gist seems to me to have gone too far. I believe him to be in error 
in his assumption respecting typhoid, as he equally is at fault in his 
conclusion touching the bronchial affection of typhus. If he had 
said, "In the cases of typhoid which have come under my cognizance 
and treatment I invariably found disease of the intestinal canal to be 
present, and in all my cases of typhus gravior the bronchial tubes and 
mucous membrane of the chest were diseased," he would have been 



GASTRO-CATARRHAL TYPHUS. 73 

correct. But cases both of typhoid and typhus of the severest char- 
acter and most prolonged continuance may occur unattended by the 
symptoms of local disease which have been regarded as so constant 
in their appearance, and which have even been asserted to constitute 
the disease of which the fever is merely symptomatic. 

At the same time we must not repudiate Rokitansky's views simply 
because they differ from those based on the study of fever in this 
country. The German observations have been made in good faith, 
and are of value so far as they are pathological records of the 
phenomena of fever as observed in a different country and as affecting 
a distinct race of people. In the typhus fever of our own land we 
often meet with serious engagement of the bronchial tubes. We not 
infrequently see a similar morbid affection in cases of typhoid; but 
in typhus this local disease always makes its appearance at a compa- 
ratively early stage of the fever, whilst in typhoid it usually comes on 
at a later period. Again, we have had in this country a form of dis- 
ease strangely opposed to all such artificial distinctions as those of fever 
under the headings of typhus abdominalis and pneumotyphus ; it was 
called gasiro- catarrhal typhus, a term which sufficiently indicates the 
character of the disease. 

To a person who is not in the habit of examining patients in fever 
very closely, the frequency and importance of the bronchial disease 
would not appear very evident or striking as he walks round the wards 
of an Irish fever hospital. We find the patient, perhaps, in a state of 
stupor, but from this he is easily roused. He is covered with petechial 
spots, red or livid, as the case may be. There is nothing remarkable 
about his breathing; he is not reported to have any cough; his pulse 
is probably 120 or 130, and his heart is weak. That patient, with 
but little hurry of breathing, not complaining of any distress, and 
without cough, may be, and frequently is, at that very time in an ad- 
vanced stage of the secondary bronchial disease. When you apply 
the stethoscope, and make the patient draw a deep breath, you are 
surprised at the great amount of disease that is revealed, although the 
symptoms of the important affection are absent. One would expect 
that in such a case there would be lividity of the countenance from 
the non-arterialization of the blood ; but here is one of the curious 
things connected with fever which it is extremely difficult to explain 
— that you will often see but little lividity in such cases. At all 
events it is not sufficient to draw attention to the condition of the 
patient's lung. In most patients labouring under bad typhus there 
is a peculiar dusky hue of the face, and this whether the bronchial 
disease were present or not. But I have over and over again seen 



<4 LECTURES ON FEVER. 

the most extensive bronchial disease, where every tube seemed to be 
half-filled, and yet where little of that kind of lividity which we see in 
a case of asthma or of bad suffocative catarrh existed. Let us con- 
sider this fact for a moment, for it is full of matter for reflection. What 
does it tell us? It announces this highly important principle, that in 
their formation, and in their progress, the secondary diseases of fever 
are, as it were, silent. They occur without the usual symptoms which 
are observed in idiopathic inflammations. They are not idiopathic 
inflammations, and therefore they have not the symptoms of them. 
Let us omit no opportunity of impressing on our minds the fact that 
these diseases are not inflammations. They form silently ; they ad- 
vance silently ; they subside silently, generally along with the fever, 
but sometimes before it has ceased. Consider for a moment the form- 
ation of a pustule in an ordinary case of smallpox. The pustule gives 
no notice of its formation. You turn down the clothes, and you find 
the arm covered with vesicles; the patient has not complained, but 
you find there is the eruption. So it is with respect to the bronchial 
disease in typhus ; so it is with respect to the intestinal disease in 
typhoid. We see the bronchial disease forming in this singular and 
latent manner, without excitement or suffering of the patient. We 
see the same in the intestine and in the heart. The softening of the 
heart, so commonly noticed in fever, is in its commencement and all 
through a silent process. The process of change up to its maximal 
intensity, and that of retrocession to the period of recovery, considered 
simply, when they are not interfered with by accidental irritation, go on 
silently. Thus the disease may proceed to its maximum without 
symptoms, and retrocede without symptoms. Now, under these circum- 
stances, I have said that, when you apply the stethoscope, you very 
often find extensive rales. These rales may be sonorous, mucous, or 
crepitating; the degree of each of those characteristics varying in 
every case, and in different portions of the lung, in the same indi- 
vidual. When you use percussion, you find that there is no dulness 
anywhere. I have not observed, in the bronchial affection of typhus 
(ever, the curious result of percussion which we see in cases of primary 
bronchial disease. I allude to increase of sonority of the chest. This 
is a very remarkable fact. In a large number of cases of acute inflam- 
matory bronchitis, it is remarked that, so far from the chest being dull, 
it is actually clearer than natural ; and this is explained by the circum- 
stance that there is a great accummulation of air in the air-cells of the 
lung — that, in fact, every little air-cell of the lung is in a condition of 
distension; it is full of air, which cannot find a ready egress during 
expiration, in consequence of the tumefied state of the bronchial tubes . 



BRONCHIAL AFFECTION NOT BRONCHITIS. 75 

and hence we have the increase of sonority. I have not observed this 
in cases of typhus fever where there was no consolidation of the lung; 
but, at the same time, it is to be noted that we have not specially 
studied this point in fever cases. When the patient draws a deep 
breath we frequently find that the rales go on increasing up to the 
very end of the inspiratory act; and in certain cases, the following 
curious circumstance is noticed, and it is one of those which illustrate 
what T have termed the silent action of the disease. On applying the 
stethoscope, you may hear but little, or a loose, rale in the larger bron- 
chial tubes, or in some of their secondary ramifications — that is, during 
ordinary breathing. If you contented yourself with such an exami- 
nation, you might come to the conclusion that there was very little 
the matter with the patient's lung — slight mucous disease in the lower 
part of the trachea, or in the very large tubes. But you might be al- 
together wrong; for, under these circumstances, it frequently happens 
that when the patient is made to draw a deep breath, you are startled 
with the extent and intensity of the rales running to the very end of 
the inspiratory act. It is in this condition that the patient's life is 
seriously endangered ; for if this bronchial disease does not retrocede, 
but continues to advance, it may happen that the sufferer falls sud- 
denly into a condition of asphyxia, tracheal rattle comes on, and he dies 
a mechanical death — in fact, he dies suffocated. You may leave your 
patient apparently going on very well, and be summoned to him in 
the course of a few hours, to find him in articulo mortis. This is a 
common occurrence, as I mentioned to you before, in persons in whom 
the bronchial disease has been overlooked or neglected. 

You will commonly hear it said that this or that patient in typhus 
has got bronchitis; and, if we were to be guided by physical signs 
alone, such a statement would seem to be correct. But I wish you to 
believe that the essence of this affection is not bronchitis, but rather 
a special condition of the air-passages, secondary to the fever, the 
result either of the typhous deposit or of the vascularity with tumes- 
cence to which I have already alluded. If bronchitis — that is to say, 
if inflammatory action supervenes — it must yet be considered as reac- 
tive and specific. I am anxious to lay stress upon this, because there 
are still many practitioners who hold that the physical signs of bron- 
chitis are sufficient to establish the existence of primary inflammation. 
Now, I do not know any characteristic difference between the physi- 
cal signs which may occur in ordinary idiopathic bronchitis and those 
which present themselves in typhus when the air-tubes are engaged. 
In both there may be sonorous, sibilant, mucous, and crepitating 
rales; and yet the two diseases are pathologically distinct. Observe 



76 LECTURES ON FEVER. 

that whatever diminishes the calibre of the tubes, whether it be 
deposit, typhous congestion, or true inflammation, will give rale; 
whatever causes secretion, whether it be true inflammation or some- 
thing the very opposite of inflammation, will give rale. We have, as 
I said before, in typhus the physical signs which are observed in true 
bronchitis ; but beware how, in any given case of fever, you conclude 
from their presence that the patient has true bronchitis. In certain 
cases there may be reactive irritation ; but never forget that the ty- 
phous disease alone, without any inflammation whatever, is competent 
to produce all the signs of bronchitis. Why do I urge this so much 
on you? Because I wish to avail myself of every opportunity of 
removing from your minds the erroneous doctrines of inflammation 
which have beenso long in vogue. We are greatly influenced by 
names; and though I do not suppose that there are many who would 
treat a case of the bronchial affection in fever with the same reducing 
measures which they would employ in the idiopathic disease, yet I 
am sure that the idea of these signs proceeding from inflammation 
makes many of us, who have not yet unlearned our early teachings, 
timid in the use of stimulants. 

We find that this bronchial disease runs a course exactly analogous 
to that of the other secondary affections of fever. It comes on in- 
sidiously, or, as I said before, silently ; it gradually advances to its 
maximum, and sometimes increases to that degree that the patient 
dies by asphyxia. This is often the case when the disease has not 
been recognized at an early period. It is in almost all cases preceded 
by the symptoms of fever for several days. I think in the best marked 
cases it first shows itself about the fourth or fifth day of the disease, 
but it may supervene at any period of the case. It subsides spon- 
taneously. You will have abundant opportunities of observing the 
following curious circumstance in the subsidence of this disease, either 
when the affection runs its natural course or when it has been neces- 
sary to treat it specially. In the true idiopathic bronchitis, when a 
patient is placed under treatment, we observe the disappearance of 
the rales to be gradual ; they are less intense and less complicated day 
by day ; and this goes on probably for a week or ten days, or it may 
be a fortnight or more, before the last shade of rale disappears. In 
the t\ phous affection, on the contrary, you will often observe that the 
most extensive, intense, and complicated rales disappear as if by en- 
chantment, leaving the respiratory murmur perfectly pure. This 
sudden di a ppearance of the physical signs is only an argument among 
many to show their non-inflammatory origin. Nothing can be more 
remarkable than this ; it seems analogous to the sudden disappear- 



SUBJECT TO LAW OF PERIODICITY. 77 

ance of the eruption of scarlatina from the skin. You may often see 
this eruption lasting for three or four days, and then suddenly disap- 
pearing, leaving the skin white and pure. Consider the case of the 
lung in the same way, and in place of the scarlatina eruption take 
the secondary bronchial disease — or eruption, if you will — and you 
can understand the occurrence of a similar change. Mind, I do not 
say this happens in all cases; and I suppose that for its occurrence 
it is necessary that there shall have been little, if any, reactive irrita- 
tion. And, as I said before, we see it in cases not only where the 
disease has been little, if at all, interfered with by treatment, but in 
others in which we have used such remedies as dry cupping, counter- 
irritation, and various stimulant medicines. Here the practitioner is 
often surprised at the rapid and complete success of his treatment, 
and may take credit to himself for bringing about a change which 
was to a great degree, at all events, induced by the operation of the 
law of periodicity, to which the secondary local effects, as well as the 
essential disease, are subject. 

In the next place we find that the best treatment in such cases is 
the stimulant. The mere circumstance of a patient having or pre- 
senting the most intense signs of bronchitis in typhus fever does not 
by any means warrant us in bleeding him, in reducing him, in exhibit- 
ing tartar emetic, or in withholding wine. Nothing of the kind; the 
best treatment for such cases is the free use of wine, ammonia, turpen- 
tine, bark, dry-cupping, and so on. 

Another argument is drawn from the interesting fact, that in a 
large number of cases of softened heart in typhus we find a combina- 
tion with the bronchial disease, and it is quite fair to conclude that 
the conditions of the lung and heart, as regards the influence of typhous 
poison on the muscular structure of both these organs, are similar. 
We have long held the opinion that what is called "effusion into the 
chest" in catarrhal typhus is a consequence of the weakening of the 
muscular structures of the bronchial tubes. The practical conclusion, 
then, to be drawn is, that the physical signs of bronchitis in a case of 
maculated typhus fever should not make you conclude that the patient 
had bronchial inflammation ; and therefore you should not treat the 
case as such. 

I have just stated that the bronchial affection of fever does not 
always disappear with extreme rapidity. Cases frequently occur 
where that affection subsides as an attack of ordinary bronchitis does 
— the rales become more scattered and less intense, and they finally 
cease. In a third class of cases, even after the essential disease has 
departed, the patient may be placed in imminent danger from effusion 



78 LECTURES ON FEVER. 

on the chest; or, again, while he may not be exactly threatened with 
asphyxia, yet his aspect and general condition may become eminently 
suggestive of the presence of pulmonary consumption. He loses 
strength, and grows pallid and emaciated. A loose cough sets in 
sometimes, with profuse expectoration. In short, the bronchial affec- 
tion simulates phthisis. Under these circumstances a quack sees the 
patient and pronounces him to be far gone in consumption. After a 
time the bronchial affection subsides, the sufferer rapidly improves — 
in fact, gets well — and the quack wins all the credit of having cured 
a case of confirmed phthisis. 

So important do 1 regard this subject of imperfect or protracted 
recovery from the bronchial disease of typhus to be, that I purpose 
to devote our next lecture to its further investigation, and to a con- 
sideration of the kindred topic of tubercle as a sequela of fever. 



LECTURE XI. 

Bronchial Affection of Fever continued — Alternating secondary affections — Imper- 
fect convalescence due to reactive bronchitis — Cases resembling phthisis— Three 
forms of tubercular disease, as a sequela of fever, (1) coexisting tubercle, (2) acute 
consequent tubercle, (3) consequent softened tubercle —Diagnosis based on the want of 
accordance between physical signs and symptoms in suspected phthisis after fever — 
Expectoration of small calculi some months after bronchial typhus — Tubercular 
fever in the typhus epidemic of 1826-27 — This fever may be contagious. 

There is a remarkable type of fever, incidentally referred to in a 
former lecture and not at all uncommon in this country, in which we 
have an alternating disease, as it were, between the abdominal and the 
pulmonary organs in continued fever. This is a very bad form of 
fever — one of the worst. We find that to-day — we shall say — the 
chest is greatly loaded, that we get no good respiratory murmur ; 
there are most intense rales, and all the symptoms of extensive disease 
of the lung are present. At this time the belly is soft; it is not ten- 
der on pressure; and there is no diarrhoea. Things go on for two or 
three days, when we find the belly to be swollen, tympanitic, tender 
on pressure; there is diarrhoea; and on applying the stethoscope to 
the chest we find it comparatively free, and the rales either gone or 
almost altogether gone. 

We turn our attention to the abdomen, and, on relieving the symp- 
toms there to a certain degree, the chest again shows signs of disease; 
and in this way the affection alternates as it were between the two 



ALTERNATING- SECONDARY AFFECTIONS. 79 

great cavities, and forms a combination which is extremely difficult 
of management. And I think that these cases of gastro-catarrhal 
typhus — that is to say, of typhus with secondary disease in the two 
cavities, that disease meanwhile alternately varying in its severity — 
are more likely to be followed by the development of tubercle after 
the disease has subsided than the catarrhal typhus without abdominal 
complication. But on this point I do not wish you to believe that my 
mind is completely made up. My opinion is one of those that men 
form gradually and unknowingly, without being able to refer the 
sources of that opinion to any particular observation. But it does 
not happen in every case that the bronchial disease of typhus either 
subsides in that sudden manner we have been speaking of or advances 
to such a height as to destroy the patient's life. 

There is another case, and a very important one, where we observe 
an imperfect convalescence, the chest remaining very much engaged. 
That is to say, after all the general symptoms of fever have subsided, 
the petechiae have disappeared, the typhous expression has vanished, 
and the patient is anxious for food, we find that the phenomena of 
the chest remain but little altered; that there is extensive bronchial 
rale. In this case it appears to me that what has happened is, that a 
reactive inflammation has occurred, and that a form of bronchitis has 
been added to the typhous disease. Something very similar to this 
occurs in the case of disease of the intestine in fever. This has been 
indicated by Dr. Cheyne as one of the cases of imperfect convalescence 
in fever. It would appear as if a secondary inflammation supervened 
upon the typhous alteration of the intestine, and this caused the con- 
valescence to be imperfect. It is extremely probable that the same 
thing occurs in the lung. There is nothing more important, gentle- 
men, in the study of diseases than to keep analogy continually before 
us ; and you may expect that the processes of disease observed in one 
cavity of the body will be repeated in the others. The case in the 
wards to which we gave the turpentine was a good example of this. 

These cases are frequently mistaken for phthisis — and this is not 
to be wondered at, for the patients have a very phthisical aspect: they 
are emaciated by fever; they have often a species of semi-hectic upon 
them; they have cough; their respiration is difficult; and they have 
frequently profuse expectoration. You will say, then, Is there any 
difference between the symptoms in these cases at this stage and those 
in cases of phthisis? I do not know of any difference but this, that in 
the patients labouring under phthisis there is often a very copious 
muco-puriform expectoration — a thing rarely seen during the presence 
of the disease in i'o\cr. It is very natural, then, that, under these 



80 LECTURES ON FEVER. 

circumstances, a practitioner seeing a patient for the first time might 
come to the conclusion that he was phthisical ; and it is quite proper 
that all physicians in this state of things should be apprehensive of 
such a condition, because it is certain that in some instances of typhus 
fever a disposition to permanent organic change in the lung seems to 
have been created by the disturbance of the system in consequence of 
the fever. 

We have three forms of tubercular disease induced in this way. 
The first is what I may term acute coexisting tubercle. This is a most 
curious form, in which, while the petechias are still on the surface, 
the lung becomes full of soft cheesy matter. 

Let me call your attention particularly to this disease. We have 
not seen many instances of it, and but on one occasion had we a post- 
mortem examination ; but this was a very well-marked case. It 
occured several years back in our wards, and was one of those cases 
which we do not easily forget. The patient, a man between 30 and 
40 years of age, had enjoyed perfect health up to the time when he 
was attacked with fever ; he was not subject to any form of chronic 
bronchitis, or of pulmonary irritation ; so that there is not the slightest 
reason to believe that tubercular matter existed in his lungs before 
he was attacked with the fever. He came here at the end of the first 
week of his illness with the usual symptoms of maculated typhus, 
complicated by the secondary bronchial disease. So far there was 
nothing unusual about the case. It was observed, however, that the 
rales were more intense in the right than in the left lung; that there 
was a greater amount of large crepitus than we commonly see in the 
typhous disease, indicating that the minute tubes were much engaged. 
The chest was perfectly clear on percussion, but I took alarm at the 
great amount of bronchial rale which had become developed at so 
early a period. The patient was treated by dry-cupping, blistering, 
and the use of senega with carbonate of ammonia; but yet we did not 
observe that these measures produced any sensible effect on the 
physical signs — a circumstance which should have still further 
increased our apprehensions, but at that time we had no suspicion of 
what the result was to be. There was no remarkable suffering; the 
patient did not complain of dyspnoea, his breathing was not much 
accelerated, and, in short, he had no symptom which would distin- 
guish his case from ordinary typhus with severe bronchial disease. 
We now, however, observed that day by day, with nothing but a 
bronchial rale, the anterior portion of the chest, especially on the 
right side, became equably yet progressively dull, although there was 
little if any change in the character of the large but crepitating rale, 



ACUTE COEXISTING TUBERCLE. 81 

nor was there any indication of hepatization — the lung always 
continued permeable to air. The petechias remained remarkably 
stationary. About the eighth or ninth day the patient began to sweat 
profusely. And this sweating appeared to occur in two paroxysms 
within the twenty-four hours, so that he seemed to have a combina- 
tion of severe hectic and of typhus fever. He died on or about the 
twelfth or thirteenth day of his disease, the front of the right side 
having become very dull, but not absolutely so, and the large crepitus 
remaining with singular constancy all through. On the day of his 
death the petechial eruption had scarcely faded. 

Although we had never had any instance of the acute development 
of cheesy degeneration pending the typhous state, yet I ventured 
to make the diagnosis of the disease here, for the physical phenomena 
were precisely those which occur in ordinary acute inflammatory 
cheesy infiltration of the lung. The right lung was found to contain 
a great quantity of soft, gray, cheesy matter, deposited in isolated 
patches, varying from the size of half a pea to that of a hazel-nut. 
The masses were not encysted; they were soft, but yet showed no 
appearance of suppuration. A few deposits of the same kind were 
found on the left side. 

The great amount of this deposit is in itself sufficient to prove that 
it was one of the secondary affections of the typhus fever; for although 
a man may live with a certain amount of chronic tubercle developed 
in his lung, it is quite impossible to conceive that he could have had 
such a quantity of soft cheesy matter, nearly filling up one lung, 
while his health and respiratory function remained unaffected, as was 
the case in this man until the occurrence of the typhus fever. 

I believe that this was but the extreme degree of what often occurs 
in fever; and we shall just now see that there are strong grounds for 
holding that cheesy matter is formed, though in smaller quantities, 
during the secondary bronchial disease of fever, and yet the patient 
recovers without having the symptoms of phthisis. 

The next form we term acute consequent tubercle; that is to say, when 
the patient has passed through his fever, and has had an interval of 
repose, everything apparently promising a perfect recovery, there is 
a sudden explosion of tubercular disease, with symptoms of high irri- 
tation, and with a rapid development of miliary and granular tubercle. 

The last form, which is not by any means so frequent as the others, 

is the consequent softened tubercle, in which, when a patient who has 

had catarrhal disease in the eurly periods of his fever has recovered, 

although with an imperfect convalescence, the- disease passes, some- 

6 



82 LECTURES ON FEVER. 

times rapidly, into the ordinary pulmonary phthisis, and is followed 
by the same result. 

I spoke to-day in the wards of a practical question, as to your diag- 
nosis, when called to a patient who has gone through typhus fever, 
and in whom the chest is very much engaged; this is a case to which 
you will be often called in consultation. The patient has been under 
the care of another person ; he has gone through severe fever; he is 
on the 25th, or the 30th, or the 36th day of his illness, and appear- 
ances of his being consumptive occur. It is possible that the patient 
may be of a consumptive family, and an alarm is excited. He has 
wasted in flesh; he has quick pulse; he may have had some sweats; 
he has cough and muco-puriform expectoration. Well, such is his po- 
sition. You are called on then to say, in the common phrase, whether 
his lungs are affected or not. You examine the chest carefully; and, 
if you find the following circumstances present, you may in most 
instances be able to assure the patient's friends that as yet the patient 
is not phthisical. If you find that the physical signs of bronchitis are 
universal, that in no part of the chest you fail in discovering sonorous, 
mucous, or muco-crepitating rales, in various degrees of combination 
— in other words, stethoscopic indications that every 'portion of the 
bronchial tree is equably affected — if, then, with this universality 
and intensity of bronchial signs, you find that the patient's respiration 
is not much excited, that he is not complaining of dyspnoea, or that his 
respiration is not rapid, you may be almost certain that the patient is 
labouring only under the remains of typhous bronchial disease, and 
that he has not yet passed into a phthisical condition. You make the 
diagnosis here, gentlemen, from a source which you will find of great 
importance: it is a diagnosis from the want of accordance of phenomena. 
What do you find here? Signs of universal bronchial affection. Now, 
we know that in ninety-nine cases out of a hundred of the development 
of tubercle after fever, where there is universality of deposit there is 
extreme constitutional suffering — there is great dyspnoea — there is 
extraordinary acceleration of breathing, so that in the case above speci- 
fied the want of accordance between the extent of disease and the 
amount of suffering leads you to a negative diagnosis, and enables 
you to declare that as yet the patient is not the subject of consumption. 
If, on the other hand, this patient had, with the physical signs which 
I have described, any hurried or difficult breathing, and the signs and 
symptoms of great irritation of the lung, it would be quite impossible 
to say that he had not consumption. In a very large number of cases 
you will find that this rule will apply. In bronchial disease following 
not only typhus fever, but a variety of other affections, you can apply 



SECONDARY INFILTRATION OF LUNGS. 83 

this rule of diagnosis very commonly indeed; in the remittent fever 
of children you can apply it; in cases of the bronchial disease which 
follows measles or scarlatina, and in a variety of other affections, the 
diagnosis from the want of accordance of the phenomena is appli- 
cable. It is very important, indeed, to study carefully those means 
of diagnosis which are available where you have not an opportunity 
of repeated observation. In most cases of consultation the consulting 
physician sees the patient but once. If you should be able to see him 
three or four times, at intervals of two or three days, you would not 
be under this difficulty ; but by this weapon of diagnosis, if I may 
make use of such a phrase, you will be able — even by seeing the 
patient but once — to give a satisfactory diagnosis. 

I have drawn your attention to the great probability that exists 
that in many cases of fever, with the secondary bronchial disease, 
there is developed not merely the affection of the mucous membrane, 
but more or less of actual organic change, consisting in a local deposi- 
tion of tubercle; and yet it does not follow that the patient will ever 
have the symptoms of phthisis. He may recover, and often does 
recover completely, with a perfectly pure respiratory murmur, with- 
out any cough, or without any symptoms whatever of disease, but 
after a period varying from three months to nine months he expecto- 
rates a few calculi. There cannot be any doubt, when all the circum- 
stances of the case are considered, that those calculi were petrifactions 
of deposits which were formed pending the fever, and which, from 
their being small and isolated, without any consolidation of the sur- 
rounding tissue, and from their having been unaccompanied by 
cavities, altogether escaped observation. The number of individuals 
who have gone through this bronchial typhus, and at some subse- 
quent period are observed to expectorate small calculi, is quite suffi- 
cient to warrant this conclusion. 

Now, looking at the entire subject, I think it more than probable 
that, in many cases, even where this proof of the previous, occurrence 
of tubercular deposit has not existed, such deposit has gone through 
a process of calcification, and the patient has not afterwards passed 
into phthisis. The cure may be effected either by calcareous trans- 
formation, absorption, or suppuration at a number of points so minute 
as to elude detection by physical means, the signs being lost or con- 
founded with those of ordinary bronchial disease. I think that this 
occurs in many cases in which we have a doubtful convalescence, 
with a quick pulse and a hectic state, in those who have had fever 
with severe bronchial disease. 

How are we to look on this tubercular deposit as a result of the 



84 LECTURES ON FEVER. 

typhous state? Were these patients already subjects of the phthisical 
diathesis, although no actual deposit had taken place at the time of 
their being attacked with fever? Or are we to look upon tubercular 
matter as occasionally one of the secondary secretions of fever? I 
strongly incline to the latter view. This much, at all events, is certain, 
that in a large number of cases there were, previously to the attack 
of contagious typhus, no existing symptoms or physical signs of 
phthisis, nor did the patients present those characteristics which indi- 
cate a tendency to this affection. Tubercular deposit, as one of the 
secondary products of fever, is probably to be looked upon as among 
the rarer consequences of the disease; for although we have seen 
many instances of it, yet in the great majority of cases of fever with 
bronchial disease there is no evidence of its having occurred. Why 
it should occur in one case, and not in another, we do not know; bat 
it is very probable that there are great varieties in the nature of the 
typhous deposit in different patients and in different epidemics. It is 
not unreasonable to suppose that the inconstancy which we observe 
witli respect to the seat, amount, periods, and complications of the 
secondary diseases of fever should be also repeated as to their 
chemico pathological characters. And thus one patient may have a 
secretion or deposit which is not tubercular, while another exhibits 
this alteration to a greater or less degree. All this, you will see, 
bears strongly on the question of the specific or non-specific nature 
of tubercle after fever; and the facts which we have just now been 
examining seem to point to the conclusion that the doctrine of tubercle 
being a purely heterologous product, resulting from a specific con- 
tamination of the system, is one which we must be cautious in accept- 
ing. But there are other circumstances in relation to this matter 
with which you should be acquainted. 

Hitherto we have been dealing with cases in which the tubercular 
formation seemed to be, as it were, an accident in the chain of typhous 
phenomena; cases in the majority of which, at all events, the actual 
amount of the deposit was geuerally inconsiderable. I have already 
spoken of one case in which a great quantity of cheesy matter was 
formed during the existence of a genuine and well-marked typhus fever, 
but in the instances hitherto under consideration we may hold that the 
deposit was but a superaddition to the ordinary secondary bronchial 
disease. Let us now inquire whether there is any evidence of a 
fever closely allied to, if not identical with, typhus or typhoid fever, and 
in which the secondary lesion is purely the deposit of tubercle — the 
tubercular matter and the fever standing in. the same relation one to 
the other as the matter of the smallpox pustule does to the essential 






TUBERCULAR FEVER. 85 

disease of variola. I cannot pretend to give you any extended infor- 
mation on this point, but the following circumstances are important. 

In the epidemic of typhus fever of 1826 and 1827 the two most 
remarkable circumstances were the great prevalence of the follicular 
disease of the intestines and the liability to relapse. In a good many 
instances it was found that the fever in the relapse was of a more severe 
character than in the first seizure. You may have observed something 
of the same sort during the present season; for we have had several 
instances in which, while the first attack ran a period of only from five 
to eight days, with the comparatively mild symptoms of what is called 
typhoid fever, the patients, on relapsing, had severe, long-continued, 
and maculated fever. In some of them, too, the bronchial system, which 
had escaped in the first illness, was profoundly engaged during the sec- 
ond attack. It was found that in several instances in which the patients 
had gone through the first attack of fever, and relapsed, they presented 
a group of symptoms very different from those in the primary illness. 
The fever was much more violent, the sufferings greater, and the 
local symptoms more numerous and decided. One case I shall never 
forget. A young woman had gone through the usual primary attack of 
fever, and recovered satisfactorily. There was nothing either in her 
previous history or in the symptoms of her fever to distinguish this 
case from that of hundreds that had passed through our wards. After 
remaining a few days in a state of convalescence, this girl was reported 
to me as having relapsed. As there was nothing unusual in this, we 
merely directed the ordinary expectorant and cooling treatment; but 
on the second or third day it was plain that the disease was taking 
on a new character. The patient had symptoms of local suffering, or 
irritation, if you will, in all the cavities. The head was hot and pain- 
ful, she was delirious; the heart was excited, and the pulse was rapid 
and wiry, the skin was burning hot, and the general symptoms were 
those of the most severe ataxic fever, with the greatest agitation and 
distress. 

But I have not yet enumerated all the symptoms of this singular 
case. In addition to the high fever and cerebral excitement, the 
patient suffered from unceasing and extreme dyspnoea, running into or- 
thopncea. The countenace was swollen and livid. There was a constant 
cough, with a scanty bronchitic expectoration, and pain of both sides. 
Then the symptoms of irritation in the belly were as well marked. 
It was greatly swollen, tympanitic, hot, and painful on pressure. The 
tongue was red, dry, and cracked; the thirst immoderate, and she 
had frequent diarrhoea.. Now, observe that no effort of ours pro- 
duced the slightest alleviation of any of her symptoms; and under this 



86 LECTURES ON FEVER. 

storm of disease she sank on the seventh day from the commencement 
of the relapse. We found, on dissection, an almost universal deposit of 
miliary and granular tubercle. • I never saw anything similar before, 
nor have I seen anything like it since. The lungs, liver, spleen, uterus, 
kidneys, as well as all the serous membranes, were implicated; and 
the amount of the disease, particularly in the lungs, liver, spleen, and 
arachnoid, was beyond anything that you can imagine. The deposit 
was of the same character everywhere. It was the disseminated tuber- 
cle, not the infiltrated, consisting of gray semi-transparent granules, 
the size of mustard seeds or smaller. In the lungs no one portion was 
less engaged then another. The little tubercles, some semi-transparent, 
others white, or yellow, and opaque, were so closely packed that they 
all but touched one another; yet each was distinct. There was no in- 
osculation, or running of one into the other ; nor was there one among 
these myriads of deposits that showed any trace of suppuration. The 
bronchial membrane was of a deep red colour, and the pulmonary 
structure, which was nowhere hepatized, presented a bright scarlet hue. 
In the spleen, which was enlarged, the deposits were nearly as abun- 
dant as in the lung ; a few of them had attained a larger size and a 
more granular structure. The pericardium, peritoneum, and arach- 
noid membrane were all studded as closely as possibly with the miliary 
tubercles. 

Now, reflect on this case. Who can doubt this extraordinary 
deposit was the result of the second attack? The very quantity of it 
is sufficient to prove this; for, if we take even the lung, no one could 
believe that this amount of disease existed, either before the first 
attack or during the period of convalescence, when there were apy- 
rexia and quiet breathing; again, remember that all these deposits 
were in the same or very nearly the same degree of development, 
and that this disease occurred in a patient who had gone through her 
first fever without any remarkable symptoms — during an epidemic 
when relapse was so frequent as to be considered almost the rule. 

Gentlemen, this might be called a tubercular fever. Call it, how- 
ever, what you will, it was a fever, with secondary lesion of a pecu- 
liar kind. This change, or local disease, was in one sense anatomical, 
no doubt, in that there was tangible visible alteration; but it set the 
local anatomical divisions of fever at nought, from the fact of its being 
universal. The disease was, indeed, as essential as the malady or 
fever which produced it. Why tubercular matter was produced here 
in such incredible quantities, and in so short a time, we do not know. 
Why, in the same epidemic, this patient, in common with many 
others, suffered in this way, while the great majority of the sick reco- 



CASE OF TUBERCULAR FEVER. S< 

vered, we cannot tell — any more than why one patient in fever, and 
in the same epidemic, shall have disease in the mucous glands of his 
intestine; a second, congestion and typhous deposit in his lungs; a 
third, an enlargement of his spleen; a fourth, a softened heart; a fifth, 
presenting all these changes combined; and so on, with an. endless 
variety. 

In this singular case it is probable that the immediate cause of 
death was asphyxia, for the lungs were almost completely filled with 
the deposits ; but there was so much local disease of the same kind 
elsewhere that it is difficult to say how much or how little the deposit 
in the lungs acted in causing death, especially when we recollect that 
the fever alone, from its very virulence and malignity, might have 
destroyed the patient. Had there been a smaller amount of tubercle 
in the lungs, she might have thrown off the fever, and afterwards died 
with the symptoms of rapid phthisis. This occurrence was observed 
by us in several instances during that very epidemic; and in some the 
period which elapsed between the efessatiftn of the fever and death, 
with all the symptoms and physical signs of suppurative tubercle, 
was not more than from ten days to a fortnight. On dissection the 
lungs were found everywhere filled with softened tubercle, which in 
many places had formed small anfractuosities. 

The observations which I have now made to you refer to the con- 
nection between fever and the occasional production of cheesy or of 
tubercular matter, as one of its secondary effects, and I think I have 
said enough to show you that tubercular deposit and the typhous state 
frequently stand to one another in the relation of effect and causet 
We might now inquire whether there are other forms of essential 
fevers in which the tubercular deposit is a necessary consequence 
— in which, to use the language at present in vogue, it becomes the 
anatomical character of the fever. You know that I am not fond of 
discussing the distinctions of fever. The cases which I have laid 
before you were examples of tubercular deposit developed in the 
relapse period of fever; and although in this relapse certain anatomical 
characters were developed, we are not on that account to say that the 
essence of the fever in its relapse was different from that in its first 
period. You all know that typhus fever may relapse into typhoid 
fever, and typhoid into typhus. I am compelled to use the expression 
of one fever relapsing into another, which is an inaccurate one, for 
want of a better, and you all must know my meaning. But is there 
any form of fever in which the tendency to produce tubercle, or the 
actual production of it, is from the very commencement a distinctive 
character? The following circumstances occurred in the practice of 



S3 LECTURES ON FEVER. 

the late Mr. Cusack, and, as far as they go, they seem to prove that 
there may be a true, essential, and tubercular fever, which also may 
be contagious, affecting many members of one family. 

An infant at the breast, eight weeks old, was attacked with fever. 
The principal local symptoms were oppression of breathing and ful- 
ness of the abdomen. The child refused its food, and death took 
place at the end of the third week. On dissection the lungs were 
found filled with miliary tubercle, and the same deposit was exten- 
sively exhibited upon both pleuras and peritoneum. 

The next case, which occurred in this family, was that of a girl 
seven years of age. She took ill just at the period of the death of 
her sister, and her symptoms were closely similar to those of the infant 
just spoken of. She had fever, oppression of breathing, and swelling 
of the abdomen. It was thought that the origin of this disease might 
be from malaria, and on this account she was removed to the country ; 
but she died within six weeks from the invasion of the fever. On 
dissection a precisely similar state of parts was discovered, the viscera 
being extensively filled with disseminated tubercle, and yet without 
any suppuration of the deposit. 

Now comes the most important fact connected with this history. 
The two brothers of this girl, who had been at school, arrived to 
spend their vacation just at the time of her death. They came to the 
country house in which she had died. Their ages were respectively 
eight and nine years. Within the first week the elder sickened; he 
had fever; oppression of breathing, soon followed by cerebral symp- 
toms; he also died with signs of effusion on the brain ; and on dissec- 
tion the pia mater, arachnoid, lungs, and peritoneum all presented 
the tubercular deposit, with the same character as in the preceding 
cases. Upon his death his younger brother sickened ; in this case, 
in addition to the symptoms of fever, the local suffering was princi- 
pally referred to the head. The child, after going through a tedious 
illness, recovered without showing any symptoms of phthisis. Dur- 
ing his illness his eldest sister, aged twelve, became affected with 
fever having the same general character as that which was presented 
in the other cases, but without any decided local symptoms; she also 
recovered. 

It might, perhaps, be better were I to leave these facts before you 
without comment, but I cannot avoid expressing my opinion that 
they go far to establish not only the existence of a form of fever of 
which the anatomical result is often tubercle, but also that this fever 
may be, under certain circumstances, contagious. 

The essentiality, also, of this species of fever is indicated in the 



SECONDARY PNEUMONIC COMPLICATIONS OF FEVER. 89 

history of the foregoing cases ; for we observe the same want of con- 
stancy as to the appearance, amount, and seat of the secondary deposit 
which is so striking a characteristic of the secondary local affections 
of other essential diseases. The fourth and fifth cases probably illus- 
trate the want of constancy observed in fevers in relation to the 
secondary affections and their results. 



LECTURE XII. 

Secondary Pneumonic Complications of Fever — Secondary congestion or consolidation 
of lung — The term "typhoid pneumonia" is incorrect — "Acute asthenic pulmonary 
disease," or "typhoid pneumonia," appears under seven forms — "Aborted typhus" 
in connection with the occurrence of lung consolidation — Local disease may assume 
a sthenic type even in the presence of a general asthenic, condition — Description of 
the secondary pulmonary affection of fever under its three principal forms — Differ- 
ential diagnosis between this disease and acute primary pneumonia, based on both 
pathological and anatomical grounds. 

The study of the affections of the lungs in fever leads us next to 
examine a class of cases in which a congestion more or less severe, or 
it may be a consolidation of the lung, takes place in connection with 
the typhous state. You have already witnessed several cases of this 
kind. In some there have been signs only of a congestive state, 
affecting a portion of one or both lungs; a state stopping short of 
consolidation, and indicated by a crepitus with large bubbles — a 
muco-crepitating rale, without much dulness, or the other signs of 
impermeability of the pulmonary tissue. In other instances, however, 
we have observed the occurrence of decided dulness. Between these 
extremes we meet with a number of cases varying in the degree or 
amount of the diseased action. 

To these cases the general term of "typhoid pneumonia" has been 
given. But you will be convinced, when your experience has been 
enlarged, that under this term many different forms of disease have 
been classed; and it is very doubtful whether a true pneumonia is 
ever developed in the course of a fever. You will meet with the 
physical signs which attend pneumonia; but these, as you all must 
know, are insufficient to establish the existence of the disease; and 
even these very physical signs are seldom so well marked, so com- 
plete as it were, as in simple inflammation of the lung. Nor, again, 
do they follow in the regular succession which we find in true pneu- 
monia. 



90 LECTURES ON FEVER. 

I am not fond of fine drawn distinctions in disease, especially when 
these distinctions are based on some anatomical speciality, and do not 
lead to any differences in our principles of treatment; and I think 
we shall arrive at practical results sooner by reviewing some of the 
more striking cases — I will not say of typhoid pneumonia — but of 
the acute asthenic diseases of the lung which tend to consolidate that 
organ. I mean, when using the terms "acute asthenic," to imply a 
disease which forms more or less rapidly, and is associated with, or 
secondary to, a condition of the system in which, with fever of some 
kind, we find evident signs of debility. Leaving refined shades of 
distinction aside, we may then recognize the following forms of the 
affection we are now considering: — 

1. Congestion, with more or less consolidation in cases of what is 
called "diffuse inflammation," "erysipelatous inflammation," or, by 
some, phlebitis. 

2. Similar or nearly similar conditions (so far, at least, as we are 
taught by pathological anatomy) in cases of purulent absorption, 
with or without manifest phlebitis. 

3. The intercurrent disease of the lung in cases of the eruptive 
fevers, when they are of the low, putrid, or malignant type. 

4. Congestion and semi-consolidations of the lung, as intercurrent 
affections in fever, and more especially in typhus fever. 

5. Analogous conditions arising in the course of the non-maculated 
and the so-called typhoid fever. 

6. The disease occurring in connection with delirium tremens from 
excess. In such cases we will often fined a group of asthenic local 
diseases, which are generally seated in the stomach, heart, the bronchial 
membrane, the parenchyma of the lung, and even the pleura and 
pericardium. In some instances we find that the patient has also 
typhus fever. 

7. Rapid, extensive, and complete consolidation of the lung occur- 
ring in the course of a malignant typhus. In some instances the patient 
dies asphyxiated, while in others a portion of the pulmonary structures 
falls into sphacelus, and death takes place with the symptoms of acute 
gangrene of the lung. 

Such are some of the more prominent cases which have been classed 
under the head of typhoid pneumonia. There is another division of 
which we have had many examples, and yet I do not wish you to take 
what I am going to say about it in any other way than in the light of 
suggestions. The case, as I said before, is by no means uncommon. 
The patient is attacked with the usual symptoms of typhus fever, and 
he comes into hospital after two or three days' illness. There is 



CRITICAL CONSOLIDATION OF LUNG. Pi 

nothing about him to make one think that his disease will not run the 
usual course of the epidemic of the day, and we are prepared to 
expect a fever of at least a fortnight's duration. On admission he 
may have no symptom which would call attention to his chest; but, as 
early in some cases as the beginning of the fourth, and in others of the 
fifth day, it is discovered that the upper lobe of one lung is solid, or 
nearly so. The clavicle is quite dull on percussion, so is the scapular 
spine, and the dulness extends to the line of the mamma, with well- 
marked tubular breathing. This discovery has been so often made 
accidentally that I am sure many of such cases have passed unnoticed, 
at least where the attendant is not well informed as to the insidious 
nature of typhous local diseases, and does not make it a practice and 
a duty to examine daily, as far as he can, the condition of every 
organ. 

But the most remarkable circumstance in these cases is that the 
constitutional disease seems to be cut short. The expression of fever 
leaves the countenance, the peculiar colour or hue of typhus disappears, 
the eye becomes bright and intelligent, the tongue cleans, and the pulse 
comes down to a natural state. And thus we have seen patients so 
altered in the course of twenty-four hours that one had some difficulty 
in recognizing them. All the symptoms of typhus were gone, and 
nothing remained but the consolidation of the lung. And this, too, is 
not attended with any notable suffering. There may be a little cough, 
some dull pain, or an inability to lie on one side ; but that is all. The 
respiration is scarcely, if at all, accelerated ; in fact, it would seem that 
there was no irritation or excitement of the organ ; and the case is an- 
other proof of how much less the sufferings in disease are connected 
with the mechanical than with the vital conditions of organs. 

By the operation of some law, which we do not as yet understands 
there seems to exist a connection between the cessation of the essen- 
tial disease and this consolidation of the lung ; the fever appears to 
abort, and the pulmonary change is critical. Under such circum- 
stances our prognosis is favourable, the fever having ceased by a well- 
marked and peculiar mode of crisis. 

This local disease, too, is generally easily managed. Indeed, the 
cure is often so rapid that I have thought that our remedies had little 
to do with the result, llow are we to look at such cases ? That they 
are not examples of inflammation of the lung is plain ; and it appears 
probable that, if this local disease had not occurred, the patient would 
have gone through the course of the fever of the day. Does it not seem 
as if the constitutional disease exhausted itself, as it were, in the pro- 
duction of the local affection, just as, in certain cases of simple variola, 



92 LECTURES ON FEVER. 

we see the fever to subside on the appearance of the pustule ? I do 
not know whether such cases have been observed elsewhere, but of their 
existence we have had here abundant proofs. It is worthy of remark, 
too, that when we compare these cases with the ordinary forms of 
typhus, attended with secondary disease of the lung, the local affection 
is developed at an unusally early period ; and it may be that, in the 
more protracted cases of fevers, the nature of which is to develop local 
affections, the periods of this development and of the cessation of the 
fever may also be coincident. We do not, however, find that this is 
so common as to establish a rule. Let us, assuming that these curious 
cases were really examples of typhus with a secondary deposit, again 
compare them with the more ordinary forms of the disease, and we shall 
find that they want two important characteristics of the longer fevers ; 
one the successive or simultaneous production of various local dis- 
eases; and the other, the occurrence of that secondary inflammation 
or irritation of the parts in which the deposit takes place. That the 
latter circumstance is one of great weight in relation to the preventing 
or delaying of crisis, it is impossible to doubt. As to the case of suc- 
cessive or simultaneous production of local diseases, this, at all events, 
marks a more severe and complicated disease. 

Gentlemen, I will not here enter into the wide subject of crisis in 
fever; yet I may point out to you, as a matter well worthy of investi- 
gation, the possibility of the occurrence of crisis by other modes than 
those which are generally enumerated; thus we may have a crisis 
without sweating, diuresis, hemorrhage, or diarrhoea, but which takes 
place by a silent change in the condition of an organ, and yet a change 
which will, or may, itself spontaneously disappear. 

Here let me warn you against a common error with respect to cases 
of disease of the lung arising in the course of some form of consti- 
tutional malady or fever. They are usually set down as pneumonia, 
typhoid pneumonia by some. Now, the name itself would be of little 
moment if its adoption did not lead to errors in practice. And 
although it cannot be affirmed with certainty that in none of these 
cases is there pneumonia, yet we have good grounds for believing 
that, in many of them, inflammation, as the term is commonly under- 
stood, is either absent from the first, or, if it occurs, that it is only 
secondary to a special lesion induced by some form of essential 
disease. 

It is difficult to give any well-defined classification of the various 
forms of diseases described under the head of typhoid pneumonia, or 
to draw the line between simple asthenic inflammation of the lungs 
and those conditions described from an early period under the terms 



TYPHOID PNEUMONIA. 93 

of bilious, putrid, or typhoid pneumonia. And observe that when I 
make use of the term asthenic pneumonia I refer more to the con- 
dition of the general system than to the activity or inactivity of the 
local disease. For so far as local inflammatory action is concerned, 
there is proof that it may originate and proceed with rapidity, and even 
with vehemence, in the very last periods of life, so that the disease 
may be sthenic quoad the local condition, and yet the case itself be 
asthenic in reference to the general state of the economy. Much of 
the confusion with regard to this subject has arisen from the circum- 
stance that too great weight was attached to the presence of certain 
physical signs, which were taken as always indicating similar vital 
conditions. The succession of the signs of crepitus, dulness, cessation 
of vesicular breathing, and its replacement by bronchial respiration, 
is too often held to indicate a simple pneumonia, in which the local 
disease is the principal condition, and the fever only a secondary one. 
But it is certain that this train of phenomena, or some modification 
of them, may occur under exactly opposite circumstances — the local 
disease being symptomatic of the fever, and not the fever of the local 
disease. And there is the strongest reason for believing that even 
though the mere anatomical condition of the lung in the two cases 
be similar, yet there is an essential, a vital difference, and that practi- 
cally we cannot deal with the local disease in the latter case as if it 
were an original affection. This applies to all those cases with the 
physical signs of pneumonia, which are secondary to any form of 
fever, whether it be typhus or typhoid, whether it be variola or ery- 
sipelas, purulent poisoning of the blood, glanders, malignant scarla- 
tina, or malignant measles. In these cases, even though the physical 
signs accurately correspond with those of the typical pneumonia — 
which, by the way, is by no means always the case — we must believe 
that we are dealing with a special condition of parts, a condition 
special not only as compared with ordinary pneumonia, but inasmuch 
as it is derived from the parent malady. 

In the present state of our knowledge, gentlemen, we cannot declare 
that any special pathological condition exists by which we can dis- 
tinguish these secondary diseases one from the other. We may say 
this much, that practically they appear to agree in being indicative 
of an asthenic state of the system, and therefore, the supervention 
of their physical signs at any period of those various diseases must 
not be permitted to divert your attention from the general condition 
of the patient, or to make you proceed to treat a case as one a 
sthenic pneumonia because it has some, or even all, of the phys ; ... 
signs of that condition. Do not suppose that I am taking up your 



9-4 LECTURES ON FEVER. 

time unnecessarily by insisting on these points, for they lead us 
directly to deal with one of the greatest, if not the greatest and most 
wide-spread error in the practice of medicine — namely, the treatment 
of all local .acute diseases with feverish symptoms as inflammations. 
Here is a group of acute local diseases with feverish symptoms, and 
not only this, but a set of cases exhibiting some or all of the physical 
phenomena of acute pneumonia; and yet if we subjected them to 
the ordinary treatment of inflammation, the worst consequences 
would almost certainly follow. You must learn to look at the ante- 
cedents and the accompanying general phenomena of these diseases, 
and set your face against the adoption of any treatment which is 
based on the doctrine that they are original inflammations. 

I have good reason to believe, and I rejoice at it, that the errone- 
ous views to which I allude are every day becoming less and less fre- 
quent, thanks to our improved system of clinical instruction and to 
the independent spirit of investigation which now animates so many 
of our students. Notwithstanding, they are still too often acted upon, 
and over and over again patients who have enough to contend with 
as the victims of some fell fever or other constitutional disease are 
lost, or assisted to their death, by the adoption of a local or general 
antiphlogistic treatment, in consequence of the physical signs of a 
pneumonia being discovered. Their stimulants are withheld or with- 
drawn ; tartar emetic, or mercury, or even blood-letting is rashly re- 
sorted to; and it often happens that, even though the physical signs 
of the pneumonia are removed or modified, the patient sinks from the 
combined effect of the original disease and the exhaustion produced 
by this treatment. I do not think that any of you will fall into these 
or similar errors, after what I have so often said ; it will, at least, not 
be my fault if you do. 

Let us now consider the parenchymatous affections of the lung in 
fever, or, if you will, the typhous disease of the pulmonary structure. 
It may be stated generally that whatever be the differences in the 
various cases of this affection in fever, the local disease follows the 
general law of other lesions secondary to the fever; that is to say, 
it agrees.with them in its frequent absence, mode of invasion, latency 
in the earlier periods of its development, spontaneous retrocession, 
and, lastly, pathological effects. It is quite true that, as compared 
with the best marked examples of acute sthenic pneumonia, it is not 
wanting in any of the physical signs of that disease taken singly, but 
it is generally different from it in the order or arrangement, as it 
wehe, of these physical signs. And, indeed, I think the rise, pro- 
gress, and retrocession of a pneumonia which has passed into hepati- 



SECONDARY PNEUMONIC COMPLICATION. 95 

zation, as we so continually see in ordinary cases of the disease, is 
rarely observed in the course of a typhus fever. I have already 
drawn your attention to those curious cases of consolidation of the 
upper lobe of the lung. Now, whether these be genuine examples of 
an arrested typhus, or not, it is difficult to say, but their whole history 
and progress is vary different from those of ordinary pneumonia; 
and I repeat that there is nothing rarer than to see in the course of 
a typhus fever that regular succession of phenomena with which 
Laennec has made us so familiar, so indicating the several successive 
stages of an idiopathic acute pneumonia. 

The most common case is the occurrence, generally at an early 
period, especially iu the maculated forms, and often at a later period in 
the non- maculated and so-called typhoid fevers, of a well-marked cre- 
pitating rale in the lower lobes of one or both lungs; it is generally 
much more extensive and distinctly marked in one lung than in the 
other. The amount of dulness is seldom very great, and we find the 
disease, as it were, to linger, and for days together to show no dispo- 
sition either to produce solidity of the lung on the one hand, or to 
proceed to resolution on the other. It is often quite latent, and re- 
cognizable only by careful physical examination ; and its discover}^, as 
you will readily understand from what I have said before, is sometimes 
an unfortunate circumstance for the patient. In the present state of 
our knowledge we must believe this condition of the organ to be 
either the result of a certain amount of typhous deposit into the lung, 
or of a special state — an inflammation, if you will — which is, how- 
ever, under the general law of the fever, partaking of its specific 
character and capable of spontaneous retrocession. It is seldom 
attended by pain or by hasmoptysis, and constantly exists without 
any important modification of the general symptoms of the case. 

The second form of the disease is of a more serious character, and 
seems to be connected either with an original pyogenic disposition, 
itself secondary to fever, or we may suppose that the typhous deposit 
undergoes a rapid purulent transformation, so that in this way a con- 
dition of the lung is established, having some resemblance to the 
third stage of pneumonia, as described by Laennec. I have not myself 
seen a sufficient number of these cases to justify me in speaking very 
decidedly as to their physical signs; but I think I have seen enough of 
them to warrant me in believing that the course of the disease is dif- 
ferent from that of ordinary suppurative pneumonia. We have not 
observed the intermediate stage of well-marked hepatization between 
that which is characterized by the occurrence of early rale on the 
one hand, and the signs of interstitial suppuration on the other. The 



9b LECTURES ON FEVER. 

complete dulness and the bronchial respiration which accompany the 
third stage of pneumonia as described by Laennec we have not ob- 
served, the physical signs being principally a persisting rale passing 
from a fine into a large crepitus, and semi-dulness on percussion. On 
dissection the lung is found soft, friable, of a grayish-red colour, but 
still very permeable to air, though infiltrated with purulent matter. It 
is as if the purulent secretion took place coincidently with, or imme- 
diately after, the first or congestive stage. Some of the patients have 
had sweatings and a sanguinolent and somewhat sanious expectora- 
tion ; but we have not hitherto observed the ordinary adhesive prune- 
juice sputa in these cases. I have seen this disease in connection with 
purulent deposits in the neck and posterior mediastinum, but it may 
occur without the formation of purulent matter in any situation other 
than the lung; it may supervene in the advanced periods of the case, 
and at a time when the patient seems about to recover, or it may 
come on much earlier, and when the skin is thickly covered with the 
petechial eruption. The last case is the most formidable ; but though 
it is attended with the greatest danger, the disease in it is, however, 
not always fatal, and we have had several instances in which recovery 
took place. I need not say that they were all treated upon a tonic and 
stimulating plan, in addition to which we employed dry cupping and 
blisters. 

The last case of which I shall speak at present is by far the most 
acute and formidable of the pulmonary affections of fever ; it is char- 
acterized by a sudden, complete, and singularly extensive consolida- 
tion of the lung. In the course of twenty-four, or even sometimes of 
twelve, hours the most extensive and complete dulness may be pro- 
duced in a lung which had been previously free from physical signs 
or at most had only exhibited some ordinary bronchial rales. We 
have thus the signs of complete hepatization, not preceded by the 
crepitating rale; the disease begins by consolidation, and then one of 
two results follows — either the patient dies speedily, generally with 
loose rales in the opposite lung, combined with tracheal effusion ; or 
after a day or two he begins to expectorate a horribly fetid matter, 
and we discover by the stethoscope that a large cavity has formed in 
the lung. This is a true gangrenous cavity in the very centre of the 
solidified mass, and the disease has a close pathological analogy to the 
process of acute mortification which has been described as occurring 
in some of the worst cases of the typhous disease of the intestinal 
glands. 

Let us now pass in review the circumstances in which these forms 
of disease occur ; for when we compare them with the ordinary condi- 



DIFFERENTIAL DIAGNOSIS. 97 

tions of aoute primary pneumonia, we cannot but admit that they 
indicate a lesion of a very different nature. 

In the first place, the physical signs are preceded by fever ; and it 
may not be until days have elapsed that the symptoms of lung affec- 
tion as it were spontaneously arise. Secondly, the fever is obviously 
an essential fever ; it may occur with or without petechia, and other 
complications may or may not be present. Thirdly, the disease sets 
in without any apparent external cause. Fourthly, when the puru- 
lent form is observed, it appears to be, not the third, but the second 
stage of the affection ; and I may here remark that, on dissection, we 
rarely, if ever, find what we may term perfectly concocted purulent 
matter. Lastly, the invasion of one form of the affection may be sud- 
den, and the signs of extensive and complete consolidation be among 
its earliest phenomena. It is in this case, too, that if time be allowed, 
large eschars, forming cavities which may communicate with the 
bronchial tubes, are liable to occur. 

I may remark here that in two cases of this rapid consolidation the 
gangrenous eschar did not communicate with the bronchial tubes- 
One was a case of severe typhus, in a man who had long before 
suffered from gangrene of the opposite lung; the other occurred in a 
case of what is termed the erysipelatous or diffuse inflammation. 

The first patient had no gangrenous expectoration. The lower 
lobe of the left lung presented a very large non-encysted and recent 
cavity, of a dark colour, filled with fetid grumous- fluid. In the 
opposite lung was found an old cavity, lined with strong fibrous 
membrane, and containing a quantity of a substance like putrid flax. 
It hacl three hollow projections, and communicated with the bronchus. 

In the second patient there was complete and recent solidity 
throughout the lower anterior part of the right lung. A cavity, the 
size of a large walnut, without bronchial communication, was found 
filled with fetid purulent sanies. 



LECTURES ON- FEVER, 



LECTURE XIII. 

pneumonic Complications of Fever, continued — "Typhoid pneumonia," so called, is 
not dependent on a coexistent gastritis — Correct view is that both pulmonary and 
intestinal lesions spring from the one parent condition, that of fever — Physical 
signs of ordinary pneumonia are often found, but in an irregular succession, in the 
secondary pneumonic affection — Sign of tympanitic resonance in latter, first de- 
scribed by Dr. Hudson — Probable causes of the production of this percussion 
sound — The author's views — Dr. Lyon's views — Three explanations of the produc- 
tion of the sign — Frequent absence of crepitus redux in resolution of secondary 
typhous disease — When inflammatory affections do occur in fever, they are reactive 
or tertiary in their nature — Typhous affection of the larynx — Rokitausky's 
" laryngo-typhus." 

I endeavoured to convey to you, at our last lecture, that the 
conditions which have been described under the head of typhoid 
pneumonia were probably examples not only of a pathological but 
of an anatomical state of parts different from that which is found in 
the simple original inflammation of the lung. And it is a great deal 
easier to say what they are not than what they are — to state their 
negative rather than their positive characters. 

Now, I wish to mention here that a certain change has occurred in 
our opinions as to the origin of the so-called typhoid inflammation 
of the lung. We at one time held that it was the coexistence of 
gastritis which gave to the pneumonia the typhoid character. This 
view was held by us before we had, by that imperceptible power of 
conviction which arises from experience, admitted the two following 
principles in their entirety : — 

1st. That symptoms which are diagnostic of local disease, where 
the patient has not an essential fever, are either altogether valueless 
or much lessened in value when such a condition exists; and 

2d. That the gastric lesion is rare even as a secondary disease in 
fever ; so that when irritation of the structures of the stomach occurs 
it is a tertiary and accidental phenomenon. 

Our present opinion on this matter is in general the following: 
that in cases in which there are, in connection with the signs of 
typhoid lesion of the lung, evidences of gastro-intestinal disease, both 
the pulmonary and abdominal lesions spring from the one parent con- 
dition, and that, so far from the specialities of the pulmonary being 
derived from the accidental complication with the abdominal disease, 



TYMPANITIC RESONANCE. 99 

both have a common character originating in the same source. I am 
quite sure that a large proportion of those cases described as 
examples of asthenic pneumonia depending on gastric complication 
have been examples of essential fever, with the two affections coexist- 
ing as secondary lesions. 

We have seen that in these cases, I will not say of typhoid pneu- 
monia, but of typhous or typhoid affections of the lung, the various 
physical signs of pneumonia, singly considered, may be present, and 
are actually often to be found. They fail, however, very frequently 
to present themselves in that regular order or succession which is 
observed in true acute pneumonia. 

Now let us inquire whether there is any physical sign peculiar to 
these cases of typhous pulmonary affections which does not occur, at 
least as the rule, in idiopathic inflammation of the lung. I do not 
know of the existence of any such, unless it be the sign of tympani- 
tic resonance over the diseased lung — a condition first noticed by Dr. 
Hudson, of this city, and to which much importance is to be attached. 
Dr. Hudson states that in certain cases of typhous consolidation of 
the lung the sound on percussion is sometimes very different from 
that observable in the ordinary condition of hepatization. He de- 
scribes it as " a tympanitic clearness over the solidified lung without 
air being present in the pleura ;" indeed, he goes so far as to say that 
in one case the tympanitic resonance on percussion existed fully to 
the same degree and was of the same kind as in pneumo-thorax. 
Here the lung was found perfectly solid throughout, with the excep- 
tion of a small extent over the anterior and postero-inferior parts 
which was still crepitating. 

It is very difficult to understand what condition of parts could have 
caused this singular tympanitic resonance over a solidified lung. 
When we speak of tympanitic resonance, it must be always borne in 
mind that the tympanitic sound does not always imply clearness on 
percussion. When a cavity exists in the centre of a solidified lung, 
or when hepatization of the left lung is present in connection with 
flatulent distension of the stomach, the sound on percussion, though 
dull as compared with that of the healthy lung, has a distinctly tym- 
panitic character; to this we have long been in the habit of giving 
the name of tympanitic dulness. I have never found it, however, to 
simulate the tympanitic resonance which occurs in pneumo-thorax, or 
in dilatation of the air cells; it is inferior in degree and different in 
character. It is probable that in cases in which the sound on percus- 
sion resembled that in pneumo-thorax, there was an actual secretion 
of air to some extent between the pulmonary and costal pleuras. Dr. 



100 LECTURES ON FEVER. 

Hudson met with four cases, in which the observation of tympanitic 
dulness was followed by dissection. One was that of a man who died 
of extensive inflammation of the left lung in the Meath Hospital in 
the spring of 1832. At the close of the case, from the hollow sound 
on percussion at the lower part of the left side — it had been pre- 
viously quite dull —a pretty general opinion existed that a pneumonic 
abscess had formed and burst into the pleura. On dissection, the side 
having been punctured, no air escaped ; the lung was red and solid ? 
but without abscess, and the pleura was adherent over two-thirds of 
its extent. 

I am quite prepared to admit that, with extensive solidification of 
the lung, the dull sound on percussion may yet have a tympanitic 
character; but I have seen no case in which this sound could be con- 
founded with that of pneumothorax, or of dilatation of the air cells. 
With reference to the bearings of this question upon the signs of 
typhous pneumonia, I can at this moment remember only two cases 
which are worth detailing to you. In one tympanitic dulness did 
occur over the diseased portion of the lung, without our being able 
to account for it by any accumulation of air either in the pleura or 
in the stomach. The case was of a low putrid character, and I 
remember suggesting it as just possible that there might have been a 
typhous pneumatosis developed in the diseased lung; but I am sure 
that we were not able to establish the existence of such a condition 
on dissection ; the case occurred a good many years ago. 

In the second case, which was one of manifest typhus, the posterior 
portion of the right lung became solid or nearly so, while the ante- 
rior face of the organ preserved its vesicular respiration. Now, we 
found that over this portion of the chest — that is, over the front of 
the thorax on the right side — the sound, as compared with that over 
the opposite lung, was morbidly clear; it was true tympanitic clear- 
ness, not dulness, and it continued for three or four days, and gra- 
dually disappeared with the resolution of the posterior solidity: this 
case occurred in the Meath Hospital, and was seen by Dr. Hudson 
himself. I confess I am quite at a loss to explain the nature or mode 
of production of this phenomenon. Dr. Lyons mentioned to me that 
in a case of asthenic pneumonia occurring in a patient of intemperate 
habits, whom we saw in consultation, the anterior superior part of 
the left lung presented for a couple of days a condition of morbid 
clearness, but subsequently became engaged in the general consoli- 
dation of the organ. 

Dr. Lyons is disposed to regard the abnormal clearness which 
occurs in these cases as the result of the increased pressure of the 



SUGGESTED EXPLANATIONS. 101 

respiratory column of air in the still permeable portions of the pul- 
monary cells, which he considers in certain cases become from this 
cause expanded beyond their natural volume. His views are that the 
inspired air presses with a certain force on the whole pulmonary 
surface, and that if a portion of this surface becomes impermeable to 
air from solid deposit, occlusion of the tubes, or other cause, the 
remaining portion of the pulmonary tissue is acted on by the whole 
of the inspiratory force, before which it is thus made to expand. 
This portion of the lung may thus be considered to be in a condition 
of temporary dilatation of the cells, and so gives a correspondingly 
clear sound on percussion. 

Dr. Hudson's discovery of this sign is of great value in many 
points of view, but, I think, chiefly as leading not only to the clearer 
distinction between ordinary pneumonia and the secondary disease of 
fever, but as a diagnostic of the essential character of the entire 
malady in the latter instance. In Dr. Hudson's cases the disease 
seemed to be the typhous affection of the lung, and the facts you will 
find in his lectures on the "Study of Fever." Many times since his 
memoir first appeared we have met with cases in our wards present- 
ing this sign in various degrees of intensity and extent. All these 
cases were examples of typhous or asthenic consolidations of the 
lung. His observations are confirmed by Dr. Hayden, in one of 
whose cases the solidified lung, though it sank in water, gave the 
same sound on percussion that had been given by the chest during 
life. 

Now, there seem to be but three explanations of this remarkable 
sign: first, the secretion of air into the pleura under the influence of 
the general disease; secondly, compression of the lung while it still 
is permeable to air; thirdly, an interstitial pneumatosis in connection 
with the typhous processes. 

Dr. Graves has shown that a temporary pneumo.-thorax without 
pulmonary fistula, and yet sufficient to displace organs, may occur in 
pneumonia. We know that a compression of the lung while it still 
continues permeable — as from liquid effusion into the pericardium or 
pleura — may cause a partial tympanitic resonance. But looking at 
Dr. Hudson's cases, at those recorded by Dr. Hayden, and at our own 
experience, it seems most probable that in the typhous consolidations 
of the lung there may occur an interstitial secretion of air, recognized 
by local resonance, and which may disappear with the subsidence of 
the pulmonary lesion. 

It is not unlikely that this condition is often overlooked in conse- 
quence of the frequent latency of the pulmonary complications in 



102 LECTURES ON FEVER. 

fever, and that the formation of air in the vessels is sometimes a 
result of fever we have direct proof. It is now some years since a 
middle-aged man was a patient in the fever ward with maculated 
typhus of the most severe kind. I cannot now say whether the 
lungs were greatly engaged, but it was the nervous system which 
seemed chiefly to suffer. Muttering delirium and deepening coma 
appeared early. These symptoms were followed by a universal sub- 
sultus, which increased to an extraordinary degree, and for the last 
two or three days of life affected, as it were, every little muscular 
fibre in the face, the incessant twitching of which produced an influ- 
ence on the expression of the countenance and an appearance I had 
never before witnessed. This continued up to the time of death. On 
dissection every vein in the pia mater and in the substance of the 
brain was found to contain innumerable bubbles of air, which were 
also present in the sinuses. 

There is a circumstance in connection with the resolution of these 
typhous diseases of the lung different from what is commonly ob- 
served in sthenic pneumonia. The true inflammatory hepatization 
rarely disappears suddenly. It subsides gradually, and the transition 
state between dulness and clearness on percussion is generally marked 
by the " crepitus redux." In the cases before us the resolution is often 
singularly rapid, and unattended by the crepitus of resolution. If, 
then, we consider the state of solidification simply, we find it on the 
one hand forming without the crepitus of the first stage of pneu- 
monia, and on the other disappearing rapidly, and without the rale 
of resolution. Thus we are permitted, as it were, to witness the silent 
and spontaneous development and retrocession of one of the secon- 
dary internal diseases of fever. 

This rapid change from the state of consolidation to that of per- 
meability to air, unattended by the crepitus of resolution, probably 
shows that the disease was unconnected with inflammation either as 
a primary or as a reactive condition. 

You will remember that I suggested to you that some of the cases 
which have been described as typhoid pneumonia might be held as 
examples of an aborted typhus. These were characterized by early 
consolidation, early disappearance of the typhous state, and a rapid 
and often spontaneous subsidence of the local disease. I cannot help 
thinking that between such cases and those in which the general 
disease runs its usual course there is another class in which the pro- 
gress of the merely pulmonary disease is marked, more or less, by 
signs of irritation or inflammation of the lung, which is either reac- 
tive or specific, or both reactive and specific. I apprehend, too, that 






SECONDARY INFLAMMATIONS IN FEVER. 103 

these cases which, as it were, float between the aborted and the perfect 
typhus, are more numerous than might be supposed ; and in such 
instances the malady is often treated throughout without a suspicion 
of its being really an example of typhous disease. 

What has been now said should impress on your minds the prin- 
ciple T have urged upon you — that the rules of diagnosis of local 
inflammatory disease which are good in ordinary cases lose their 
value in a great measure when the patient has fever. This was long 
ago proved by the researches of Louis on the condition of the brain 
in fever, and it was the non-recognition of this fact which constituted 
one of the greatest errors of Broussais. I have told you that if you 
gained nothing during the session but the knowledge of this prin- 
ciple, your time would have been well spent. How many cases have 
we not had of headache, delirium, watchfulness, or its opposite, coma, 
yet without encephalitis? And so it is with the remaining cavities — 
symptoms of functional alteration are met with in connection with 
the cerebral, pulmonary, circulating, and digestive systems in fever. 
They may or may not be attended by organic change, and that organic 
change, when it does exist, is not necessarily inflammation. We 
cannot, I believe, lay down any satisfactory rule of diagnosis which 
would show that in one case of local functional disturbance there was 
organic change, and in another there was not. 

I do not seek to teach you that inflammation, with prominent 
symptoms, and calling for local antiphlogistic treatment, never occurs 
in fever. You must be cautious in using the word " never" in medi- 
cine. That true cerebritis has been met with in fever is certain, 
especially in the form of meningeal inflammation. But it seems prob- 
able that this occurs less frequently in the head than in the chest or 
abdomen, and it is almost certain that when it does exist it is not a 
primary but a reactive inflammation. 

It becomes one of the most difficult problems in practice to distin- 
guish between the functional and organic affections of the nervous 
system in fever. The secondary lesions of the brain vary as to their 
frequency according to the character of the epidemic, as we have seen 
in the late prevalence of the black fever, or — as it has been called — 
the cerebro-spinal fever. But the great point to be remembered is 
that these cerebral lesions have all the characters of the secondary 
affections— namely, their inconstancy in amount, seat, period of ap- 
pearance, their mode of 'retrocession, intensity, and incompetence to 
account for the characters of the general malady. Let this principle 
be ever present to your minds, for it is impossible to exaggerate its 
value. Long ago it was acted on empirically by the best physicians, 



104 LECTURES ON FEVER. 

who refused to adopt antiphlogistic measures in treating the local 
symptoms in fever, and who employed stimulants irrespective of them, 
when the general condition seemed to demand such treatment. It now 
comes before you as the result of an extended observation, and the 
study of the pulmonary phenomena, as we have seen, enables us to go 
a step further, and to declare that not only are the symptoms of local 
irritation often doubtful or illusive, but that even the physical signs 
of pneumonia, when occurring in a case of fever, are not to be taken 
as proof that a local inflammation has occurred. 

If these things be true so far as essential fever is concerned, it 
would appear probable that in other acute diseases under the influ- 
ence of a law of periodicity, and, perhaps, in many that arise from 
the operation of an introduced poison, the same circumstances may 
be found, so that we might apply to a much larger circle of diseases 
those principles, as to the secondary local affections, which belong to 
fever. 

In speaking of the bronchial membrane in fever, we said nothing 
with respect to lesions of the larynx or trachea as a result of the 
fever. Taken as a localized disease, I would say that this lesion is 
not very commonly met with ; and we may safely hold that it is by 
no means so frequent in the petechial fever of these countries as it- 
appears to be in the fevers of the Continent. 

This is the condition to which Rokitansky has given the name of 
laryngo-typhus, by which he means a secondary lesion of the mucous 
membrane of the larynx and trachea, analogous to that of the bron- 
chial membrane. It is, then, a secondary affection of the fever de- 
veloped in the windpipe, and either confined to that part or predomi- 
nating in it. I think it probable that in most cases of this disease 
there is an associated affection of the bronchial membrane. But, so 
far as the fever of this country is concerned, the converse of the 
proposition does not hold good; for we constantly see the most pro- 
found bronchial affection without tracheal or laryngeal symptoms. 

We have met a few cases which would answer to the description of 
Rokitansky's laryngo-typhus. A more proper name for this disease 
would clearly be "a typhous affection of the larynx." In those cases 
which we have seen, the symptoms were loss of voice, or a certain 
degree of hoarseness ; the cough never was the so-called tussis clan- 
gosa, although it often partook of the laryngeal character, and I do 
not remember any instance of stridor but orie in connection with the 
other laryngeal symptoms. In some cases the weakness or hoarse- 
ness of voice continued for a considerable time, and did not disappear 
until convalescence was far advanced. 






LARYNGO-TYPHUS. 105 

I have often thought that, in these cases, the lesion of voice was to 
be attributed more to the weakness or paralysis of the laryngeal 
muscles than to any form of irritation or inflammation of the mucous 
surface. For although we cannot bring any observations from dis- 
section to throw light on this point, we may fairly believe that the 
laryngeal muscles are liable to be affected in fever, just as the mus- 
cular fibres of the heart are often found to be ; that the same process 
which causes a typhous deposit in the mucous surface may be re- 
peated in the vocal muscles ; and that a certain time must elapse 
before these organs recover their healthy condition. They may also 
be weakened quite independently of any structural change, just as 
occurs in the heart; for in this latter organ there are doubtless two 
forms of debility in connection with fever — in the one, we have 
weakness with actual softening of structure; in the other, a debility 
which appears to be purely nervous. 

This leads me further to draw your attention to the probable exist- 
ence of similar conditions in the circular, and perhaps also in the 
longitudinal, fibres of the bronchial tubes in this secondary disease. 
I have little doubt that such a condition exists in many instances, 
and that a weakness, with or without softening of these structures, 
becomes an important element in the bronchial disease of fever. If, 
as some modern authorities have urged, these circular fibres are really 
the expectorating muscles, we can readily see how any weakness or 
paralysis affecting them would greatly increase the danger of a 
patient already suffering under copious secretion into the bronchial 
tubes. We can further understand not only how this condition 
would superinduce what is termed "effusion into the chest," but also 
why it is that in the treatment of the bronchial disease of fever there 
is such danger from the employment of the antiphlogistic method, 
and how, on the other hand, such admirable results follow from the 
bold use of tonics and stimulants. 

When we come to speak of the heart in fever, I will draw your 
attention to the fact that in many of our most remarkable examples 
of typhous softening of that organ there was a great amount of the 
secondary bronchial disease; and in such cases you will constantly 
see the associated diseases of the heart and the lung progressing or 
retrograding simultaneously, the treatment adapted to the one being 
suitable also to the other. In the heart, so far as we know, we have 
to deal with an affection only of the muscular structure; in the lung 
we have at least two different forms of anatomical structure affected 
— the muscular and the mucous tissues. But the existence of the 
essential typhous state so far affects these tissues that their vital con- 



106 LECTUKES ON FEVER. 

dition is depressed in a similar manner ; and it happens that what- 
ever is tonic and stimulant, to the one is equally so to the other, and 
so by supporting and augmenting the vital energy of both structures 
we can add the assistance of art to the efforts of nature in throwing 
off the disease. 

In connection with the subject of laryngo-typhus, I remember a 
case of complete aphonia without any other laryngeal symptom in a 
patient suffering from fever for some days. There were no signs of 
any disease in the upper portions of either lung, and we were at a 
loss to explain the symptom. After a few days the chest was again 
examined, when it was discovered that the postero-inferior portions 
of both lungs had passed into complete consolidation. For this the 
patient was treated, and resolution was. established in the ordinary 
way. Simultaneously the voice began to improve, and was shortly 
quite restored. The explanation of the occurrence of aphonia in this 
case is difficult, but it may be that the symptom was due to reflex 
irritation of the pneumo-gastric nerve, dependent on the condition of 
consolidation in a portion of the lungs. 



LECTURE XIV. 

The Heart in Fever — The state of the pulse, especially iu typhus, not always a 
reliable guide — Weakening of the heart may coexist with a full, bounding pulse 
— Slow pulse in convalescence is consequent on a typhous weakening of the heart 
— Rapid pulse in convalescence is of unfavourable import, pointing to (1) tubercu- 
losis, or (2) secondary reactive inflammation of the mucous glands of the intestine, or 
(3) phlegmasia dolens — In such cases the local malady assumes the prominence 
hitherto presented by the essential disease — Illustrative case of hepatic abscess 
in convalescence from the yellow fever in 1826-27 — Intermittent fever at close of 
epidemic of 1827 — Frequency of phlegmasia dolens — Bleedings in cold stage, after 
Dr. Mackintosh — Failure of quinine in cases of simulative ague, arising from (1) 
phlegmasia dolens, (2) urinary disease, and (3) the puerperal state. 

Next in order I shall speak of the conditions of the heart in fever 
— a topic which calls for our most attentive consideration. 

From the. earliest times physicians have been in the habit of rely- 
ing on the pulse as a guide for the administration or the withholding 
of stimulants in fever. Now, I must tell you that in typhus at least 
the pulse is not always to be depended on as a truthful indication. 
In true typhus one of the most unreliable and illusory symptoms is 
the state of the pulse, especially in the earlier stages of the disease. 



THE HEART IN FEVER. 107 

For instance, in a case of the true petechial character you may find 
the patient, even on the fourth day, with a full and bounding pulse, 
while within 24 hours the whole condition will have changed. Now, 
this state of pulse has too often led to errors in practice both of com- 
mission and omission — of commission, from the adoption of general 
or local depletion ; and of omission, from the postponement of the 
necessary treatment, owing to the apparent inflammatory condition 
of the system. The opportunity is lost of employing nutrient and 
stimulant remedies in time. You, gentlemen, educated as you have 
been, and taught to look on fever with an eye rather to the general 
aspect of the disease that to its local accompaniments, will not, I 
trust, fall into this error. I tell you that in typhus fever, at the very 
time when the pulse has that full, bounding, and seemingly inflam- 
matory character, debility of the heart, with or without softening, 
may already have set in. As regards the circulatory system, I will 
say to you : Examine closely the state of the pulse, and then the 
character of the heart's action. If both coincide in vigour, so far so 
well; but you must be prepared to find very often a full and bound- 
ing radial pulse coinciding with a feebly acting heart — a condition 
probably progressive. Here we have evidence of the necessity of 
anticipative treatment, and commonly of its good effects. 

We have now passed in review some of the important typhous 
affections of the lung. I have told you that in cases of this kind 
there have been frequently signs of an analogous condition in the 
muscles of the heart, and to this subject I now crave your attention. 

Long ago Laennec stated that in certain cases of low fever he found 
the heart in a softened condition — in what he termed Vetat poisseux of 
the muscles of that organ. He did not recognize the real nature of 
this condition, but held it to be evidence of the degeneration of the 
muscular structure of both the voluntary and the involuntary sys- 
tems, resulting from the dissolution of the fluids in putrid fever. He 
suggested whether in those cases of fever which exhibit rapidity of 
pulse during convalescence this symptom is to be attributed to a soft- 
ening of the heart. This opinion is not well founded, the true 
typhous softening of the heart, so far from being followed by rapidity 
of pulse during convalescence, has much more frequently the effect 
of making it slow — slow not only as considered with reference to the 
condition of health, but actually falling below the ordinary standard. 
That rapidity of pulse is commonly associated with typhous affections 
of the heart, in which there is a weakening of the organs while the 
fever continues, must be admitted. But this is a different proposition 
from that advanced by Laennec, who speaks of the symptom during 



108 LECTURES ON FEVER. 

convalescence. Many of the greatest triumphs of the stimulant treat- 
ment in our wards have been seen in cases where the pulse was as 
high as 140 in the minute, the effect being to lessen its frequency 
from day to day until the period of convalescence was reached. 

I have little doubt that Laennec met with the true typhous soften- 
ing of the heart, although he misinterpreted its nature. You may 
take it as an established fact that in typhus the heart may be softened 
to the most extreme degree, while the voluntary muscles remain 
intact. And you may further rest assured that rapidity of pulse in 
convalescence, so far from indicating any remains of the typhous 
disease in the muscular structure of the heart, is in most cases a proof 
of the existence of some lurking disease of some important organ or 
organs. I say in most cases, for we sometimes meet with instances in 
which this state of things cannot be discovered, and where the quick- 
ness of pulse shows that the heart had contracted a habit of rapid 
action, which it requires time to get rid of. But these cases are 
exceptional; and whenever you find rapidity of pulse in a patient 
who has thrown off his fever, you are to take alarm. 

These cases of quickness of pulse are of two kinds. In one class 
the pulse has never lost the rapidity it attained during the fever; or 
it has, perhaps, come down fifteen or twenty beats in the minute, and 
its rate then remains stationary. In the other cases the pulse, which 
had become quiet, again rises to 100 or 120, or even higher, and 
remains at that increased rate for days together, without our being 
able to detect any cause for this rapidity. The latter is, I think, the 
worse case of the two ; at least it appears oftener to indicate a new 
pathological change. 

The local diseases which most frequently attend this condition are 
of two kinds — one of them is tuberculosis in the lungs and other 
parts; the other is the existence of a secondary reactive inflammation 
in the mucous glands of the intestines. 

But now suppose that you examine a patient having a quick pulse 
in convalescence with great care. You percuss his chest ; you ex- 
amine the state of his respiration in every way ; yet you cannot sat- 
isfy yourself that there is any disease in his lung ; and you will recol- 
lect what I mentioned in a former lecture, that in most cases of this 
tuberculosis after fever there is great local and constitutional suffering. 
Well, you may make up your mind, from the absence of all these 
signs, that the patient is not becoming tuberculous at all events. On 
proceeding to examine the abdomen, you will find, perhaps, that he 
has a good appetite; that his thirst is gone; that the belly is soft, 
without any tumefaction ; that there is no tenderness on pressure 



QUICK PULSE IN CONVALESCENCE. 109 

anywhere, no throbbing of the abdominal aorta, no tendency to diar- 
rhoea — in fact, no symptom whatever of disease of the mucous mem- 
brane of the intestine. And yet, as in the case in the small fever 
ward, you have a pulse with this unpleasant degree of quickness. 
Although this patient has convalesced after a long fever, and is now 
gaining flesh and strength, we have found that the pulse continues 
rapid. I rather think that it is now quicker than on the 21st day of 
bis illness, and it makes me extremely uneasy about him. 

Now, gentlemen, suppose that under such circumstances you did 
not find disease either of the lung or of the abdomen — in this patient 
the signs of abdominal and pulmonary lesion have disappeared, as 
well as the characteristic expression of what may be termed the con- 
dition of fever — what should you suspect? Generally you may look 
for phlegmasia dolens ; for we have seen many cases in which, after 
fever, the pulse continuing rapid, this disease exploded. This is, I 
think, more likely to occur in the non-petechial than in the petechial 
cases, in the long than in the short fevers ; it is very liable to arise in 
patients who have had a fever running on beyond twenty-one, thirty, 
or forty days. These patients, after the true symptoms of fever have 
subsided, remain with a rapid pulse, and probably in a week or so 
symptoms of phlegmasia dolens come on. The disposition to this 
complication is sometimes remarkable, for you will very often find 
that the patients have two or three distinct attacks of it. It may 
affect one leg, and the patient may pass through that attack ; still the 
pulse does not regain its natural rate. After a week or ten days the 
other extremity will be attacked ; nay, it is even possible that a third 
seizure may occur — a relapse, as it were, of the disease in the part 
first affected. In this way patients will go on labouring under the 
affection and its consequences for months together, although recovery 
ultimately takes place. 

In most of the cases I have seen there was distinct notice of the 
invasion of the disease — that is t6 say, the patient was attacked with 
pain in the calf of the leg. He is seized, say, in the course of the 
night, and in the morning he exhibits all the characteristics of the 
disease — a large swelling, pain on pressure, and all the other symp- 
toms. Sometimes you find a cordy state of the superficial veins; at 
other times, not. When you can feel a deep-seated vein, you will 
occasionally find it in a hard and cordy state. 

I think it right to warn you of these contingencies, for I am sure 
that in the course of your practice you will often have a patient re- 
covering from fever, and going on in every respect well, except that 
the pulse does not come down. The rule then is, that, if the most 



110 LECTURES ON FEVER. 

minute examination fails to detect disease in the great viscera, the 
occurrence of this complication may be looked for. 

The term phlegmasia dolens is not always applied correctly, for the 
disease is not necessarily painful. We have seen a few instances in 
which the discovery of the local affection was entirely accidental. 
Of course you will not suppose that T am confident that the patient 
in the ward will have phlegmasia dolens; all I say is, that he is in 
that state which would justify you in suspecting something of the 
kind. 

I have mentioned the rapid deposition of tubercle, ulceration of the 
intestines, and phlegmasia dolens of the lower extremities, as the dis- 
eases we have found to occur most commonly in these instances of 
apparently unaccountable quickness of the pulse after fever. Doubt- 
less there are many more examples- of local disease arising under 
these circumstances ; but the general rule will hold good, that this 
symptom foreshadows a disease which, although at first lament, will 
before long become manifest. 

These diseases are generally attended with much irritation, and the 
condition of the patient is one rather of irritation, or inflammation if 
you will, than of essential fever. And this is one of many illustra- 
tions of a circumstance often observed by the clinical investigator — 
namely, the change of character of disease, locally and constitutionally 
in the same patient, and within a not very extended period. The 
typhous condition, generally considered, changes into a different state. 
The essential state disappears, and a local irritation, with its symp- 
tomatic fever, becomes the prominent malady. Nay, you will find 
that the very condition of a local disease, formed during the first — 
the typhous or essential — period, will itself change, and take on the 
characters of what is termed by some a "healthy inflammation." 

You may sometimes see this well illustrated in that terrible disease, 
accompanied by purulent deposits in many of the articulations, which 
may be called "idiopathic pyaemia."' The patients may throw off the 
typhoid state which attends the earlier periods of the disease, and 
then the affection of the joints seems to change in its nature, and to 
take on the characters of ordinary arthritis. I have, however, seen 
this only where one or two of the larger joints had been affected 
with the primary disease; and it was most remarkable to witness the 
changes both in the constitutional state and in the local affection. It 
was no longer necessary to use general stimulation ; it was no longer 
improper to employ local antiphlogistic measures. 

You will see in the article on " Hepatic Abscess," in the " Cyclo- 
pasdia of Practical Medicine," a case which we may well study in 



INTERNAL ABSCESS IN YELLOW FEVER. Ill 

connection with this subject. The patient was a middle-aged man, 
who was attacked with the yellow fever, of which we had such strik- 
ing examples in the epidemic of 1826 and 1827. A valuable account 
of this disease is to be met with in Dr. Graves' "Clinical Medicine." 
This patient was the first who was saved. The treatment which I 
adopted on the appearance of the jaundice and the spasms of the 
belly was the free application of leeches to the abdomen, the use of 
calomel and opium in full doses, and a liberal allowance of wine. 
The man recovered, to our great surprise ; but whether from the 
measures employed, or from the circumstance that the epidemic was 
then losing its malignity, it is difficult to say. However, his recovery 
seemed perfect ; the pulse became natural ; the yellowness rapidly 
disappeared ; no gangrene of the limbs or nose had occurred ; and he 
was finally discharged, to all appearance quite recovered. 

Within a fortnight he again applied for admission. He was evi- 
dently very ill. The pulse was rapid. He had copious sweats. The 
breathing was hurried, but not laboured, and he had a hacking dry 
cough. I at first suspected that his case was one of the acute conse- 
quent tubercle which I have already described to you. I could dis- 
cover no sign of abdominal disease, and the physical examination of 
the chest, repeated with great care from day to day, gave results very 
different from those observed in the acute deposition of tubercle after 
fever. There were neither the intense and persisting bronchial rales 
nor the progressive dulness ; and so I remained in the most unhappy 
of all positions to which a physician can be exposed — namely, that 
of having to treat an acute disease of which he knows neither the 
seat nor the nature. However, the suspense did not last long. In a 
few days, at the time of visit with the class, I found him coughing 
up purulent matter, and the nurse showed us a vessel which held 
more than a quart of the same fluid, which the patient had coughed 
up during the night. The expectoration had come on suddently. 
On the day before I had made a most minute examination of the chest, 
both anteriorly, and posteriorly, and had failed to discover any sign 
of disease. Yet we now found that the posterior portion of the left 
side, as far as the scapular spine, was absolutely dull. There was no 
bronchial respiration, no resonance of the voice, and, I think, no rale. 
We came to the conclusion that an abscess, probably of the liver, had 
opened into the chest. I will not go into the details of our treatment, 
which was that usually employed in cases of internal suppuration. 
The patient rapidly recovered, and left the hospital without the 
slightest physical sign of disease in either the chest or belly. During 



112 LECTURES ON FEVER. 

the next ten years I had repeated opportunities of seeing this man, 
who continued to enjoy the most perfect health. 

This case is well worthy of your careful study. It shows, in the 
first place, that rapidity of pulse, after convalescence, probably indi- 
cates some profound lesion ; next, that we were right to pause before 
making the diagnosis of acute tubercle, when there Avas a want of 
correspondence between the physical signs and the constitutional 
symptoms. It is an additional illustration of the possible existence 
of hepatic abscess, without perceptible hepatic tumour; and, lastly, 
it is remarkable as being the only instance during that singular epi- 
demic tendency to yellow fever, in which organic change of the liver 
seemed to occur. Dr. Graves dwells strongly on the point that in 
none of our dissections did we find hepatitis; and it is quite possible 
that, even in this case, during the violence of the first attack — that is, 
when the patient had the yellow fever — the liver was not inflamed, 
and that its subsequent suppuration may have been owing either to 
abdominal phlebitis or to a pyogenic diathesis. I assume that the 
abscess was in the liver; but even this is not absolutely certain. It 
assuredly was not originally in the chest. Whether the purulent 
matter made its way into the lung by a perforation of the diaphragm, 
or whether the case was an example of vicarious action of the lung, 
thus removing the purulent matter from the liver, are questions which 
can never be answered. 

As I have alluded to the invasion of phlegmasia dolens after fever, 
I may mention a case which occurred many years ago in this hospital. 
You all know that intermittent fever is a rare disease in this country. 
It is not endemic in our vast mountain districts, nor in our level 
boggy plains; and, indeed, for many years we never had a case of 
ague in hospital that did not occur in the person of one of the 
labourers who went to the fenny districts of England to cut the 
harvest. These men were often attacked with ague on their way 
home, the disease being immediately excited by the cold, wet, and 
fatigue to which they were exposed on their journey. At the close 
of the epidemic of 1828, intermittent fever became very general; in 
fact, it was epidemic, and for a time almost every case in our wards 
was an example of some form of ague. 

It was at that time that I tried the treatment of bleeding, in the 
cold stage, as recommended by Dr. Mackintosh. Our results, in a 
very large number of cases, were decidedly opposed to the practice. 

Now, at the time when the wards were filled with intermittent 
fever, a patient was admitted with symptoms of tertian ague. As 
was natural when so many cases of the same form of disease were in 



SIMULATIVE AGUE. 113 

the house, this did not excite any special attention, and the man was 
ordered quinine in the usual doses. But the disease did not yield to 
the specific ; on the contrary, the paroxysms became more severe, and 
the type of the fever changed to quotidian. I then became alarmed. 
I stopped the use of bark, and proceeded to make a careful exami- 
nation of the patient. No signs of disease were found in the chest 
or belly, but it happened that in throwing off the bed-clothes for the 
purpose of examining the lower part of the abdomen I accidentally 
exposed the lower extremities. The thigh and leg at one side proved 
to be greatly enlarged. The whole extremity was white and elastic, 
and the saphena vein iu a cordy state. Now, this man had never 
complained of any local pain or uneasiness, and was as much sur- 
prised as I was at the state of his limb. He was treated by leeching 
and the use of calomel and opium, and speedily recovered. He had 
no paroxysm of the fever after the change of treatment. 

I have hardly a doubt that this patient's life would have been lost 
but for the circumstance that we omitted the quinine in time. Not that 
I wish you to suppose that the swollen leg after fever is itself a very 
dangerous disease ; for we have no reason to think it more so than 
ordinary phlegmasia dolens ; but I believe that the persistence in the 
use of bark in cases of simulative ague is fraught with danger. Indeed, 
there is here a double danger, for we thus not only neglect but exas- 
perate the acute disease. 

You are all familiar with the intermittent fever, which is symp- 
tomatic of urinary disease. On this subject, and on the danger of 
mistaking the affection for ague, and treating the case with bark, the 
late Mr. Abraham Oolles used to dwell with great force in his lectures 
on surgery. 

There are, doubtless, many other instances where a local irritation 
excites a fever, which, for a time at least, has all the characters of a 
true intermittent. Puerperal women are liable to this disease ; I do 
not allude to the true puerperal fever, but I have often known women 
soon after child-birth to be attacked with well marked tertian or 
quotidian fever, in whom it was difficult, or impossible, to discover 
any local disease of importance. In some there had been an abortive 
irritation as it were : perhaps some tenderness of the uterus which 
had been removed by treatment; or in others a tendency to inflam- 
mation of the breast — but these had subsided, and the intermittent 
fever persisted. I have over and over seen bark administered in such 
cases, and always with bad results. The tertian was changed into 
quotidian or double tertian, the quotidian into double quotidian, and 
in one case, where the use of bark was persevered in for a length of 



114 LECTURES ON FEVER. 

time, the patient sank with symptoms of inflammation in the abdomen 
and lungs. I believe that for the treatment of this condition we 
should trust to change of air, good diet, opium, and nervines. I have 
known one case in which the practitioner had given bark to a great 
extent, with the effect of exasperating all the symptoms, in which, 
when the medicine was omitted, draughts of valerian, ether and opium 
used, and the air changed, the disease rapidly disappeared. 



LECTURE XV. 

The Heart in Fever, continued — Louis' conclusions, based on post-mortem observations 
— Typbous softening of tbe beart daring life first studied at the Meath Hospital in 
epidemic of 1837-39 — As regards state of tbe beart, fever cases fall into three cate- 
gories : tbose accompanied by (1) no alteration in heart's action, except of rate ; (2) 
weakness after a few days, consequent on depressed vital power ; (3) cardiac excite- 
ment — Neither a depressed nor an excited state of the heart in fever necessarily 
implies organic change — Dynamic condition of the heart a more important indica- 
tion for treatment than presence or absence of any structural change — True carditis 
very rare in fever— Typhous weakening predominates in left side of the heart — 
State of involuntary muscular fibre in acute essential disease is of great importance 
— Laennec's theory as to typhous softening of heart erroneous, for there is no cor- 
respondence between the softening of voluntary and involuntary muscular struc- 
tures — Illustrations from yellow fever of 1826-27 — Exemption of heart from typhous 
affection is a grouud for a favourable prognosis — Continued excitement of heart 
equally a ground for a bad prognosis — Excited beart with compressible pulse most 
unfavourable — Transfusion of blood under these circumstances — Absence of red 
blood after death, the only noteworthy pathological appearance in this case — Blood- 
waste in fever to be met by administration of nourishment. 

It may be taken for granted that most, if not all, internal organs of 
the body are liable to become the seat of the secondary affections of 
fever ; and the symptoms having a more or less common character, 
varying only according to the seat of the disease and the liability to 
reactive irritation, it would be strange if the heart formed an excep- 
tion to the rule. 

I have shown you that Laennec occasionally observed a softened 
state of the heart in persons who had died of fever, but that he did 
not recognize this muscular change as distinct from that general con- 
dition of the voluntary muscles held to proceed from the dissolution 
of the fluids. 

Louis, in his great work on the pathological anatomy of fever, 
corrects the doctrine of Laennec, and shows that in his cases where 
softening of the heart was met with after death " no similar lesion 



OBSEKVATIONS OF LAENNEC AND LOUIS. 115 

was found in any muscular organ, as all the muscles which preside 
over voluntary motion preserved amid the general disorder their 
natural colour and consistence." He established the following points 
as the result of his dissections: First, that the softening he observed 
was not the consequence of putrefaction ; secondly, that it was often 
partial, affecting more the systemic than the pulmonary heart; thirdly, 
that it was to be met with apart from any analogous condition of the 
voluntary muscles ; and fourthly, that it was not inflammation, but, 
to use his own words, " something the reverse of inflammation." He 
further found that the disease was best marked in proportion as the 
fever was earlier fatal, being much more frequent in those which died 
from the eighth to the twentieth day than in cases in which life was 
more prolonged. 

It is to be remarked that neither by Laennec nor by Louis are any 
observations recorded which would lead to the discovery of this 
typhous condition during life. I have pointed out that the suggestion 
of Laennec with reference to a rapidity of pulse during convalescence 
from fever is not to be accepted. With a view of determining 
whether, pending the existence of this typhous change in the heart, 
we could establish its diagnosis — and in the hope of attaining some 
degree of precision in treatment as regards the employment of stimu- 
lants, a series of researches was commenced in the wards of the Meath 
Hospital during the epidemic of 1837-39. These were continued 
more or less for the next ten or fifteen years. You will see the 
original memoir in the Dublin Medical Journal, 1 in which it is, I 
think, sufficiently proved that the typhous secondary condition of the 
heart is not difficult of diagnosis ; that it is, like the other local con- 
ditions of fever, inconstant in its occurrence and amount; that its 
advance and retrocession often follow the corresponding changes in 
the general malady ; and that by its recognition and study we are 
greatly assisted in the use of stimulants and of nourishment in the 
treatment of many cases of fever. 

Now, as regards the state of the heart in fever, you may divide the 
cases roughly into three categories. In the first there appears to be 
no alteration whatever in the heart's action beyond the usual increase 
of rate which belongs to fever. This is a condition which we have 
found most often in cases of what may be called benign, though they 
may be well-marked fevers. They are not malignant fevers, and so 
far as the impulse of the heart and the character of its sounds are 
concerned, little or no alteration occurs. These cases run a compara- 

1 First series, vol. xv. No. 44, 1839, p. 1. 



116 LECTURES ON FEVER. 

tively regular course, unforeseen accidents and complications are rare, 
and tbe subservience of the disease to the law of periodicity and to 
judicious treatment are remarkable. The second is that wherein, after 
a few days, we have weakness of the heart consequent on depressed 
vital power. The third and worst of all is that in which we find 
cardiac excitement of more or less violence existing through the entire 
or a considerable portion of the illness. 

Even in. the case of the two last-named categories — that wherein 
there is depression of the heart's action, often attended with softening 
of its substance, and that in which violent excitement of the organ is 
met with — you must bear in mind that neither the depressed nor the 
excited condition of the heart in fever is enough to justify the infer- 
ence that any organic mischief is present. It is true that we not 
infrequently find a softened state of the muscular structure, yet with- 
out marks of inflammatory action, in cases where well-marked 
depression and feeble action of the heart have existed. But where 
intense excitement of the heart's action has prevailed, we may meet 
with no evidence of anatomical change, with no sign of inflammation. 
The softened state which is associated with the weakened dynamic 
condition is wanting, and the heart has a perfectly normal and healthy 
aspect. 

What I wish to convey to you is this, that as regards prognosis and 
treatment we have to look rather to the dynamic condition of the 
heart than to any structural change in its tissues. Thus we may have 
all the signs of extreme weakness of the heart without the occurrence 
of any softening ; and, on the other hand, the heart's action may be 
excited to an extreme degree where inflammation will be completely 
absent. You are, therefore, not to have recourse to antiphlogistic 
measures merely because the heart is excited ; and, again, you are not 
to infer that there is actual softening where the heart's action is 
depressed. It is true that feebleness of sounds and impulse attends 
softening of the heart, yet in certain cases their rapid reappearance 
under stimulants seems to show that a depressed innervation may 
exist for a time independent of the softening of the organ. 

As regards the use of stimulants in fever, you are to look more to 
the vital than to the organic changes of the organ. We have deter- 
mined that signs of a well-marked and continued depression of the 
heart's energy are commonly associated with actual softening — at least 
it was so in one epidemic — and, on the other hand, that even a con- 
tinuous excitement in fever may occur without any carditis. In fact, 
true carditis seems to be extremely rare in fever; and this might be 
expected when we remember how seldom the serous membranes are 



DEGREES OF SECONDARY CARDIAC LESION. 117 

affected in the disease. I have before spoken of the rarity of organic 
disease of the heart traceable to an attack of typhus or typhoid fever 
— which contrasts so remarkably with what is seen in rheumatic fever. 
This will prepare you for believing that the excited state of the heart 
in fever, when it does occur, rarely calls for any interference. And 
experience shows that we must be very cautious in the use of stimu- 
lants in such cases, not from their exciting influence on the heart itself, 
but from their disagreement with the nervous system. 

In cases of convalescence, where the heart has been depressed, and 
probably softened, the returning vigour of the organ is an indication 
that the stimulants should be lessened or given up. 

It is, then, with the depressed condition of the heart that we have 
principally to do. As I have said to you already, this state is com- 
monly associated with a softening of the muscular structure due to 
the secondary influence of the fever poison. It arises, as it were, 
silently in the course of the fever, and it subsides spontaneously, 
leaving the structure — organically at least — in a state of health. 

In regard to the weakening with or without softening, we find that 
it predominates in the left side .of the heart, so that our researches 
confirm those of Louis. We have, it is true, found a very few cases 
in which, both the ventricles being engaged, the right appeared more 
softened than the left, but this was entirely exceptional. Although 
in our typhus fever debility and softening of the heart predominate 
in the left ventricle, yet — when it is more accurately compared with 
the fever of the Continent — future observations may show that the 
softening of the right ventricle is of more frequent occurrence than 
in the cases observed by Louis. 

The investigations as to the state of the heart in typhus may be 
said to belong to our own time. The pathological anatomists of the 
Continent, although they investigated so closely the post-mortem 
appearances in fever, neglected the examination of certain portions 
of the system, the reason being that they were seeking rather to estab- 
lish a theory than to arrive at the whole truth. Hence the condition of 
the muscular fibre in a number of diseases has been much neglected. 
Even at the present day the best works give us very imperfect infor- 
mation as to the abnormal conditions of muscular fibre, whether of 
the voluntary or of the involuntary systems. Much remains to be 
discovered upon this point. 

In connection with acute disease of the internal parts the state of 
the voluntary muscles is, probably, not of much importance, but 
with regard to the involuntary muscles it is far otherwise. 

The larynx, trachea, and lung arc muscular organs, so also is the 



118 LECTURES ON FEVER. 

digestive tube, and there is reason to believe that muscular fibre exists 
in other places where it has not as yet been described. But of all the 
involuntary muscles the heart is the most remarkable, both from a 
physiological point of view and in the manifest changes which it may 
exhibit in the course of an essential fever. 

I have mentioned that Laennec considered the softening of the heart 
in fever an example of general muscular softening depending on the 
dissolution of the fluids. Now, you may believe that neither in fever 
nor, I apprehend, in any other disease, acute or chronic, is there any 
necessary connection between the state of the voluntary and that of 
the involuntary muscles. Louis has shown that the softening of the 
left ventricle and its friability were sometimes so great as to cause 
the heart to break down on the slightest pressure, while the voluntary 
muscles preserved their firmness, and were in a perfectly healthy 
state. 

Our observations are strikingly confirmatory of this. We have 
seen patients with every one of the conditions termed putrescent — 
with black petechias, gangrenous sores on the back, sordes on the 
teeth, and fetid and bloody discharges — and nevertheless when we 
came to examine the voluntary muscular system after death, it 
appeared perfectly red and firm, exhibiting well-marked cadaveric 
rigidity. I remember very well that when those frightful cases of 
yellow fever occurred in this hospital, the disease commonly attacked 
the strongest young men — models of muscular development. In 
these subjects, notwithstanding the malignity of the disease, the black 
vomit, and the gangrene of the extremities, the condition of cadaveric 
rigidity was most remarkable and long continued. 

In a very small proportion of cases in which we found the typhous 
softening of the heart, we did observe something analogous to such a 
change in a class of muscles which may be termed " mixed " or 
"semi-involuntary." Thus in two or three instances where the heart 
was softened we found a certain amount of softening of the pectoral 
muscles, but except in this portion of the voluntary system there was 
no departure from health. 

Now, looking at the action of the heart in fever, you will see cases 
in which, for a time at least, nothing abnormal exists; even the rate 
of the pulse may be long unaffected, though this is rare. This often 
varies, being sometimes quicker and sometimes slower, but with this 
exception there is nothing abnormal observed in the whole course of 
the case. There is neither increase nor loss of impulse, no lessening 
of either sound of the heart, no unusual preponderance of one sound 
over the other; in fact, if you except the alteration of rate, there is 



ESCAPE OF MUSCULAR SYSTEM. 119 

nothing abnormal as regards the heart; yet, though this condition 
may continue all through the case, and is a ground of a good prog- 
nosis, there are examples where it has continued for three weeks, and 
then a complication of bad symptoms has appeared. This we have 
observed more in typhoid than in maculated typhus. 

That this occasional escape or exemption of the heart from mischief 
is a favourable circumstance there can be no doubt ; it shows that, 
like other organs in fever, it may be untouched in certain cases by the 
secondary processes of the disease. This bears on the point we have so 
often insisted on — the variableness of all local affections as to seat, 
intensity, and time of appearance in essential disease. One patient 
may have the heart engaged ; in another with the same character of 
fever it escapes. That is all we can say. 

In the next category we place the cases of excitement of the heart 
— a condition justifying an unfavourable prognosis, especially when 
it is a continued one. It may exist in the earlier periods of the 
fever, and continue after the symptoms of prostration have set in, 
when the heat of the body falls and the pulse becomes feeble, con- 
trasting strongly with the force or vivacity of the heart's action. 
This is a very strange condition, but one full of danger. It is not 
yet understood, and we have failed to connect it with any anatomical 
change in the heart. In some patients it may continue all through 
the case; in others it is ephemeral — that is to say, it exists for two or 
three days and then subsides, though it may return. 

In others, and these seem to be the worst cases, the heart during 
the early and even the middle period of the fever has not been affected 
with depression or the signs of softening, when we observe the terrible 
symptom of an increasing excitement of the organ with an increasing 
weakness of the patient. When you apply your hand over the heart 
you find it acting violently and with a jerking character, similar to 
that of ordinary nervous palpitation — a quick, sudden, violent action 
— while both sounds are loud, sharp, and distinct. Any of you not 
accustomed to such cases would expect to find a strong resisting pulse, 
but it is not so ; you may find it extremely small ; it may be just per- 
ceptible and easily compressible, and it is a fact that this excited action 
of the heart may continue for days when every trace of pulse at the 
wrist has disappeared. This condition of the heart, whether it has 
existed all through, whether it is intercurrent or ephemeral, or, as we 
say, terminal — coining on at the close of the case — or lasting many 
days, is, I need not tell you, of the worst augury. 

You will ask, What is this affection ? Is it inflammation ? We have 
every reason for believing that it is not so. Is it an example of that 



120 LECTURES ON FEVER. 

functional state of organs in fever of which I have spoken ? Certain 
it is that in our dissections in these cases we do not find anything 
abnormal in the heart — no vascularity, no lymph, no alteration of the 
valves, no inflammation of the aorta, not a single anatomical evidence 
of inflammation. 

A good many years ago we had a case of excited action of the 
heart with progressive failure of the pulse. A woman had been 
employed in washing the clothes and bed linen in a case of severe 
maculated typhus. She was admitted in a bad form of fever, with 
great prostration. The heart soon assumed the excited and jerking 
action ; the pulse was rapid and weak. "Wine had no good effect, and 
about the twelfth day her condition seemed hopeless. N pulse could 
be found at the wrist, and the skin was cool, as was also the breath. 
None of the ordinary local diseases could be detected, though the 
excitement of the heart continued. Under these circumstances I 
determined to try the transfusion of blood, and the operation was 
performed by the late Mr. Smyly. About twelve ounces of freshly 
drawn blood, not defibrinated, were thrown in, with the effect of 
restoring the pulse, so that it could be reckoned, and of making the 
breath warm. The action of the heart remained unchanged, but the 
patient sank in about thirty hours after the operation. 

On dissection, conducted with great care, no anatomical change or 
lesion whatever could be detected in any of the cavities. The heart 
was empty and the ventricles firm, while the posterior portions of the 
lung presented nothing of the congested state common in fever. The 
whole lung posteriorly as well as anteriorly was perfectly white, dry, 
and apparently bloodless. It seemed as if all the blood, at least the 
red blood of the body, had disappeared in the course of the fever, a 
condition which I believe was first noticed by Laennec. 1 

1 It is now some years since Dr. George Harley was led to believe that in certain 
cases the colouring matter of the blood was to be found in the urine, under the guise 
of what he termed uroKcematin. This substance closely resembles the hsematin of the 
blood in appearance and properties, and especially in the fact that it contains iron. 
If the quantity of urohsematin is in excess, its presence is readily detected by a 
deepening of the colour of the urine on the addition of some nitric acid, the effect 
being heightened when the mixture is heated. From his investigations, Dr. Harley 
is inclined to regard urohaBmatin as the debris or the product of the colouring matter 
of the red blood corpuscles, and he considers the amount of the substance present 
to be to some extent a gauge of the destruction of red blood corpuscles in health or 
in disease. I need scarcely say how interesting the examination of the urine would 
be in a case similar to the one just detailed. The discovery of a very marked excess 
of urohsematin under such circumstances would have supplied a missing link in the 
diagnosis of an extreme blood-waste. 



THE HEART IN FEVER. 121 

It has ever since been a cause of sorrow to me, remembering the 
law of periodicity in fever, that in this case we did not repeat the 
transfusion. The restoration of the pulse in the radial artery, and of 
the warmth of the breath, showed that by the operation we had gained 
time. 

T have little doubt that this lessening of the quantity of the blood 
in fever occurs more or less in many cases independent of local disease 
or excessive discharges, and this you will at once see bears strongly 
on the point of the careful and continuous giving of nourishment in 
the course of fevers. I believe that this is beside the question of the 
use of wine or other stimulants in fever. 



LECTURE XVI. 

The Heart in Fever, continued — Depression of the heart, more marked in typhus 
than in typhoid — Signs of the change connected with (J.) the impulse, (B) the 
sounds — The phenomena attending depression are variable — Description of their 
development, generally from the fourth day. 

A. Impulse: — Possible sources of error in diagnosis: (1) constitutionally feeble 
impulse, (2) emphysema of lungs — Necessity for comparison of condition of heart 
from day to day — Peculiar modification of impulse in certain cases — Vermicular 
action — Effect of position on impulse of heart — Loss of impulse generally progres- 
sive, sometimes rapid — " Where differential diagnosis is difficult or impossible it 
is often unnecessary as a guide to immediate practice" — Retrocession of the local 
malady is gradual. 

B. Sounds : — First phase of lesion : second sound becomes relatively, but not posi- 
tively, augmented. Second phase : disappearance of first sound. Third phase : 
disappearance of both sounds (a condition of most unhopeful augury) — Foetal 
character of the sounds in some cases — Speculations as to failure of second sound 
— Loss of impulse and failure of sounds generally advance pari passu, but not in- 
varibly so — As failure of sounds begins at the left side, so in recovery the pheno- 
mena follow the inverse course. 

We must now speak of the third and most important condition — 
as regards treatment — of the heart in continued fever. We have 
spoken of its quiescence and its excitement, and we are now to study, 
first, the signs of depression of the heart in fever ; secondly, how far 
those signs are diagnostic of the softened state described by Louis; 
and, thirdly, the general nature of that change. 

The phenomena attending depression of the heart are of more 
importance in the maculated typhus than in the typhoid fever; at 
least they appear earlier — often much earlier — and seem to be more 
connected with softening in the former. As you might expect, the 



122 LECTURES ON FEVER. 

state of depression is recognized by the characters of impulse and of 
sounds. Now, after what I have so often impressed on you in the 
wards, I need not urge the importance of the principle that, in de- 
ducting practical conclusions from the phenomena of the heart, their 
value will be derived not from the comparison or contrast of one 
patient's case with that of another, but rather from the study of each 
case with itself at different stages of the disease from its commence- 
ment to its termination. 

Now, as regards the action of the heart in fever there are many 
interesting phenomena to be studied. You will, of course, understand 
that they will not prove to be constant in future epidemics or in all 
countries. I have no doubt that the secondary affections of the heart 
are under the same rule of variability as to occurrence and intensity 
as are the other lesions in fever. Now, I suppose that you have a 
case of maculated typhus, in which this secondary affection sets in. 
You will often find after the third or fourth day that the impulse of 
the heart has diminished to a remarkable extent, and this may happen 
gradually, but we have observed it within twelve or eighteen hours — 
that is, in a patient whose heart was beating naturally yesterday its 
impulse is hardly perceptible to-day. Generally, however, we find 
that the vivacity of the heart's action is progressively and gradually 
lessened, and that the change is plainly perceptible about the fourth 
day. Instead of the normal healthy beat of the heart, there is a 
sluggish, laboured, and heavy motion. The diminution or cessation 
of its impulse is first observable at the apex, when the stroke of the 
heart is either not to be felt or scarcely perceptible. As the disease 
goes on, you will have to make pressure in the direction of the base 
of the heart or in the region of the xiphoid cartilage, in order to be 
sensible of its action at all. It will be generally found on close 
investigation that this cessation of impulse commences at the left side 
— a fact again confirmatory of the researches of Louis, that softening 
of the heart in fever begins in the left ventricle. Recollect, however, 
that there are not a few persons who, although enjoying average 
health, have hearts with a really feeble action, or apparently without, 
or with very little, impulse, and this may save you from the error of 
necessarily attributing to the typhous weakening or softening pheno- 
mena which may be simply natural or constitutional. Bear in mind 
also that feebleness of the sound and impulse may be caused by an 
emphysematous state of the lung, which has the effect, as it were, of 
burying the heart deep in the thorax. 

Now, remember what I said to you about the advantage of the test 
of comparison, not so much of one patient with another as of the 



VERMICULAR IMPULSE. 123 

state of the same patient at different periods. If you find the heart's 
impulse lessened or gone, and know that it was present on the day or 
two previously, you have evidence that the change in the impulse is 
owing to the influence of the fever. Also, if you perceive the loss of 
impulse to be progressive — that is, that it becomes daily feebler and 
less perceptible — you may set this down as the result of the typhous 
weakening of the heart. Under such circumstances, on giving stimu- 
lants and nutrients, you may be suprised at finding the impulse greatly 
restored ; yet this effect, I must observe, is commonly transitory in its 
nature, for it is only when the disease has run through its stages and 
has been safely passed that you can look with any certainty for a 
permanent restoration of the vigour of the heart. The restoration, 
however temporary, of the impulse under the use of stimulants goes 
so far to indicate that its weakness was one of the secondary condi- 
tions of the essential disease, and as fully subject to the law of peri- 
odicity as the petechial eruption, the discoloration of the skin, or 
any of the other local secondary phenomena of fever. 

I have told you that the loss of impulse is generally first observed 
at the left side of the heart, but you will meet with cases where it 
commences over the right cavities. But whether the signs first appear 
here or on the opposite side, when both cavities are engaged the 
impulse becomes undiscernible from the languor of the contractile 
power of the entire heart. If, say on the fourth day of fever, the 
impulse begins to languish and grows progressively weaker each day, 
you need entertain no doubt of its typhous character. 

In these cases of diminution and at last extinction of perceptible 
impulse we have often observed a modification of the impulse that is 
interesting. It marks a feeble action of the ventricles in which the 
contraction is, as it were, not sudden but progressive. Instead of the 
suddenly occurring, promptly ceasing, and well defined beat of the 
heart, the impulse has a beat of a vermicular character, as if all the 
contractile muscles of the ventricle did not act at the same moment. 
In cases where the feeble impulse is visible you can sometimes satisfy 
yourself of this vermicular action by the eye, and, as you might 
expect, there is a certain prolongation of the first sound at the apex 
approaching bellows murmur. 

Now, under such circumstances the heart is about to be, or has been, 
greatly weakened, and accordingly you may find this physical sign 
in the earlier periods, when the process of softening is on the advance, 
or again at a later period, when the organ is recovering. I think it 
is an important indication that actual softening has occurred, and that 
the feebleness of the impulse and sounds implied something more 



124: LECTURES ON FEVER. 

than failure of nervous power of the organ. It may be present, 
especially as a sign of recovery, for one or two days, and this is seen 
in cases of slow convalescence from a state of extreme prostration. 

In estimating the amount of failure of the impulse I must give you 
some cautions before you conclude that there is no impulse. While 
the patient lies on his back it may happen that the mere application 
of the hand below the mamma will lead you to believe that impulse has 
ceased, yet you are not at once to conclude that this is so. You must 
make pressure downwards with the hand, and if still you do not get 
impulse you are to apply the tips of your fingers to the intercostal 
space firmly, and you may then feel the action. Nor are you to 
declare that there is no perceptible impulse until you examine the 
patient, turning him well on the left side and applying the hand as 
before. If this fails to detect the stroke you may believe that the 
most extreme weakness of the organ exists. 

The loss of impulse is generally progressive, though sometimes 
rapid. You will find it at first difficult to distinguish between weak- 
ness combined with a process of softening, and simple debility with- 
out organic change. But this is of no great practical importance, at 
least so far as immediate action goes ; it illustrates the great principle 
in clinical medicine, of which you have seen so many examples, that 
where differential diagnosis is difficult or impossible, it is often unne- 
cessary as a guide to immediate practice. The process, like other 
secondary affections in fever, begins silently, without preceding signs 
of excitement, except perhaps rapidity of action. 

There is nothing more interesting than to observe from day to day 
the retrocession of the local malady and the restoration of the organ 
to health. In general the return of the impulse is attended with that 
of the sounds, though we have seen exceptions to this. Thus the 
sounds may return before the impulse, while we have had cases in 
which eight days elapsed after its return before the sounds were re- 
established. 

Let me again impress on you that the value of the lessening or the t 
want of impulse of the heart in fever as an indication of depression, 
without softening, depends on the observation of a good impulse 
during the earlier period of the case, as this will prove that the 
feebleness or want of impulse was not the natural condition. 

Now, as to the character of the sounds — looking at the circum- 
stances connected with the impulse, and at the pathological state of the 
heart, you will be able to predicate the results of auscultation. As 
the impulse is lessened, it may be to extinction, so it is as to the 
sounds. The change appearing first, at least in the great majority of 



DIMINUTION OF SOUNDS. 125 

cases, in the arterial side of the heart, the sound of contraction of the 
left ventricle becomes feebler and feebler, while that of the right, 
though it may be lessened, continues. The second sound becomes 
relatively, though not positively, augmented, and this may be taken 
as showing the first phase of the lesion. 

Next we may have a similar state of things as to the right ventricle, 
and then it commonly happens that we find the heart acting with but 
a single sound, and that sound the second. In a few extreme cases 
all systolic and diastolic sounds cease, and we have the strange condi- 
tion of a heart acting, yet so feebly that it has neither impulse nor 
sounds — even in this state the pulse may continue perceptible. 

But there are variations of these signs in different cases, all, how 
ever, showing a depressed and probably a softened state of the organ. 
Both ventricles may be engaged, causing diminution of their sounds, 
while the second is also lessened. Neither sound is extinguished, but 
both are greatly and apparently equably reduced. In this case, when 
the pulse is rapid — say 130 or 140 in the minute — the resemblance 
of the sounds to those of the heart of the foetus in utero is singular. 
So similar are they that I believe if an observer was blindfolded, 
brought to the bedside, and made to use the stethoscope, he would 
think he was examining the abdomen of a merely pregnant woman, 
and not the thorax of a male subject in typhus fever. 

Were we to speculate on the causes of the lessening of the second 
sound, we might ask, Does it depend on the condition of the heart 
itself, or on that of diminished resiliency of the aorta and pulmonary 
artery — a secondary effect of the fever? But it is unnecessary in the 
present state of our knowledge to discuss such points. It is enough 
to know that this condition is one, though an exceptional one, of the 
signs of debility of the heart in fever. 

Now, touching the sounds of the heart, you may take it as a general 
rule that the diminution of impulse and the feebleness of the sounds 
advance pari passu. Yet this is not invariably the case, and I must 
tell you that you are not always to infer the loss of impulse from the 
disappearance of the heart's sounds. It is certain that in fever we 
may have a good impulse, apparently a healthy one, although the 
cardiac sounds may be very obscure. Ou the' other hand, the sounds 
of the heart may be found natural and satisfactory while there still 
exists a decided loss of impulse. Generally, however', the two groups 
of phenomena are found to go together, the one being indicative of 
the other. 

We may, for the sake of perspicuity, consider the phenomena of 
the sounds of the heart in fever under three forms. In the first there 



126 LECTURES ON FEVER. 

is a departure from the normal proportion — as to force, clearness, and 
persistence — which the first sound should bear* towards the second. 
In the second we have the diminution of both first and second sounds. 
You will perceive that in the first form the inequality arises from 
weakened action at one side of the heart, while the other remains 
unaffected. Here both are partially enfeebled. In the third form the 
sounds at both sides cease to be discernible even to the keenest ear. 
This last change involves a condition in which successful treatment is 
rare, and it may supervene on one or other of the former two changes 
already described. Either of the first two may terminate in the last, 
or total cessation of both sounds of the heart. 

Now, all these signs — including those which go to make up the 
third group of phenomena detailed — seem to indicate that the vital 
power, and frequently the organic structure of the heart, are pro- 
foundly affected. 

It is, however, to the characters of the first sound and to the impulse 
that your attention in practice is chiefly to be turned. During the 
whole range of an investigation into these phenomena in fever, which 
has extended over a long series of years, neither I myself nor the 
gifted students who have laboured with me could ever say that we 
met with a single case of fever in which the peculiar phenomena of 
cardiac debility began with diminution or cessation of the second 
sound of the heart. Whatever may be the cause which produces the 
second sound, one thing is clear — that it has much less relation to the 
vital character and condition of the heart than has the first sound. 

I have mentioned that where the sounds of the heart become altered 
in the course of a fever the change begins in the left ventricle and 
travels towards the right side of the heart ; the systolic sound first 
becomes diminished towards the left, and afterwards towards the right. 
In cases of recovery the phenomena follow the inverse course, as we 
might naturally expect. We find the returning first sound audible, 
first over the right, and then over the left ventricle. 



THE HEART IN FEVER. 127 



LECTURE XVII. 

The Heart in Fevee, continued — Post-mortem appearances in extreme typhous softening 
— This affection not followed by chronic disease of the heart — Periods of invasion 
and of retrocession — Diagnosis of actual softening depends on (1) the character 
of the fever, and (2) the persistence of physical signs of failure of the heart — 
Simultaneous lessening of both sounds (fetal heart) — Its bearing on the treatment 
by stimulants — Slowness of pulse in convalescence from typhous softening — An- 
alogy to fatty degeneration of heart with slow pulse — In latter case the phenome- 
non, however, is constant — Occasional reversal of the order in which the signs of 
typhous softening show themselves — Prognosis more favourable with depressed 
than with excited heart — Former condition is more amenable to treatment — Report 
on an epidemic of typhus at Stockholm in 1841, by Professor Huss — Cardiac Mur- 
murs in fever, especially in advanced stages of typhoid and relapsing fever, are 
generally basic and systolic, functional in character, and occasionally accompanied 
by venous murmurs in the neck — Difficulty of distinguishing the first and second 
sounds of the heart in certain cases of disease : (1) chronic bronchitis, with weak 
and irregular heart and congested liver ; (2) late stages of some forms of fever — 
Example of the latter — Diagnosis drawn from a want of accordance in the symptoms. 

Before we proceed to consider some of the remaining secondary 
conditions of fever it will be right to return, in this lecture at least, 
to its influence on the heart, not so much as a question of pathological 
anatomy, but as having an important bearing on the two great objects 
of medical science, the cure and the prevention of disease. 

We have studied some of the signs of typhous affection of the heart 
— a state commonly one of depressed vital energy, attended with a 
softened condition varying in its amount and extent, and following 
the laws of the secondary organic and functional affections in fever. 
Many of you have had an opportunity of studying this condition 
during life and after death. It may be described as a change in the 
muscular structure, which is certainly not inflammatory. There is 
but little, if any, change in the volume of the organ, which latter is 
often more or less livid, as you may see in other structures in fever. 
Serum is sometimes found effused into the pericardium, but beyond 
this there is no affection of the external covering, the endocardium, 
or valves. The structure of the heart, most often of the left ventricle, 
becomes homogeneous, and in it to the naked eye the muscular fibre 
can hardly be detected. It is of a dark colour, and has some resem- 
blance to the cortical structure of the kidneys. It seems infiltrated 
with an adhesive secretion, and is softened and friable, breaking down 



128 LECTURES ON FEVER. 

under a slight pressure. This change may be more or less general, 
though it commonly predominates in the left ventricle, where it may 
occur in patches from a quarter to an eighth of an inch in breadth 
and an eighth in depth. So great is the softening in extreme cases 
that where both ventricles are almost equally engaged, on grasping 
the great vessels and turning up the apex of the heart, we find the 
whole organ to fall over the hand like the cap of a large mushroom. 

That this is a special and secondary local disease in fever there can 
be no doubt. I have spoken of its variations in intensity, extent, and 
time of retrocession. Like other secondary diseases, its frequency 
varies according to the epidemic character, for though it has for many 
years been observed in our wards and studied in connection with the 
necessity for and employment of stimulation, yet it was certainly 
more frequent before the epidemic of 1847 than it has been since that 
time. It was not a very prominent symptom in the famine fever of 
1847 and 1848, and its subsequent rarity, as compared with what was 
observed in the decade following 1837, may have been connected with 
the general disappearance of fever in Ireland for some years after the 
famine fever. Like the other secondary affections, too, it often exhibits 
retrocession without consequent disorganization. In fact, there is no 
example of reactive irritation or inflammation, such as we see in the 
lungs or intestines, having ever occurred in the heart. Out of many 
hundreds of cases observed since 1837 to the present time, we have 
had no example of chronic organic disease of the heart traceable to 
the typhous affection. 

The period of invasion of this manifestation appears to be between 
the fourth and sixth day of the fever, and its retrocession takes place 
at varying times between the tenth and the fifteenth day. The physical 
signs of weakness may be said to continue for about eight days. 

The diagnosis of actual softening, as distinguished from simple de- 
bility, will depend on the character of the fever and the time during 
which the physical signs of failure of the heart have been present. 
Experience, again, shows that the progressive diminution of the impulse 
and sounds of the heart, which may proceed to their extinction, is 
sufficiently often connected with the actual softening to justify the 
diagnosis of this lesion. 

The energy of both sounds may be simultaneously lessened, and 
where this takes place to a certain degree they resemble those of the 
fcetal heart. This, we have thought, in some instances showed an 
irregular and anomalous case, in which the stimulating treatment, 
although manifestly indicated, was not so successful as in the ordinary 



SLOW PULSE. 129 

case of diminution or obliteration of the first sound while the second 
remained. 

A remarkable character of the pulse — one to which allusion has 
already been made — during convalescence, in cases of unquestionable 
softening of the heart, which had been treated by free stimulation, is 
the progressive diminution of its rate even below the normal standard. 
In these cases, when convalescence is already advanced, when the 
heart's impulse has been restored and its sounds have again become 
audible, the pulse, having fallen to 72, on the next day will be found 
to beat but 60 times a minute. This lowering of rate may go ou for 
several days afterwards, until at length the pulse will have fallen per- 
haps to 48, 40, or even 36, when once more it rises in a similarly 
gradual way to the natural standard of health, at which it finally re- 
mains. The return to the natural standard, however, though progres- 
sive, is effected in a shorter time than was the gradual fall in the first 
instance. It js difficult to assign a cause for this peculiarity of pulse, 
but a similar slowness of the pulse undoubtedly exists in many cases 
of fatty degeneration of the heart. 

It is very difficult to account for this slowness of pulse supervening 
when convalescence is all but established, not only as to the general 
symptoms, but as to the heart itself, which exhibits a return of its 
natural vigour. In the fatty degeneration of the heart the pulse, which 
we have found as low as 28 in the minute, is more or less perma- 
nently slow. The rate may rise to 36, but the power of attaining 
the natural standard seems lost. You will remember, however, that 
in this condition the muscular structure is permanently damaged, 
while the typhous affection is under the law of periodicity. 

I must tell you that although in the majority of cases the typhous 
change is marked in the first instance by the failure of impulse, and of 
the ventricular sound — these signs being most developed at the left 
side of the heart — you may meet cases in which they vary in their 
seat and order of occurrence. I have impressed upon you that fever 
is an essential condition. Yet when you study it in a number of 
cases, even during the same epidemic, though you may find among 
them a generic resemblance, they present infinite varieties in the local 
symptoms and signs — varieties as to seat, intensity, the occurrence, 
amount, nature, time, and complication of the secondary affections. 
Hence you may expect to meet with departures from the usual suc- 
cession of phenomena as to the functional as well as the organic changes 
of the heart. The former may be ephemeral, the latter variable as to 
their retrocession. Signs of excitement may alternate with those of 
depression, and the order of phenomena as regards the first and second 



130 LECTURES ON FEVER. 

sounds of the heart may (though this is rare) be reversed. This great 
principle remains, that the disturbances of the heart in fever, even 
when it shows excitement, are very rarely indicative of inflammation, 
while the nature of the morbid change is truly "something the re- 
verse of inflammation." 

Turning to prognosis, it is clearly to be more favourable in the case 
of depression than in that of excitement of the heart, and looking at 
the frequency of softening, you arrive at the conclusion — which seems 
a strange one — that the existence of such a change in one of the most 
important organs of the body may lead to a better prognosis than 
under opposite circumstances. The reason of this, however, is obvious. 
In the case of the typhous softening we can safely and advantage- 
ously employ stimulants, which are comparatively ineffective, and 
often inadmissible where the heart is excited. The condition of de- 
pression of the heart is certainly more frequent in the well-marked 
maculated fever than in the typhoid form. It begins,, at all events, 
earlier, and the signs of progressive softening and recovery are much 
better defined. Still it would be wrong to say that in the typhoid 
cases the examination of the heart is not of great importance. When 
we shall speak of treatment and of the use of stimulants, you will find 
that in the advanced stages of typhoid a very great amount of stim- 
ulation is often borne with the best results. 

Before passing from the subject of the state of the heart in fever, I 
wish to draw attention to a very interesting report upon an epidemic 
of fever which occurred in a corps of gens d J armes stationed at 
Stockholm in the winter of 1841. The observations made in this re- 
port by Professor Huss are very confirmatory of our researches at the 
Meath Hospital. The disease in this outbreak had most, if not all, the 
characters of our typhus. 

The skin was maculated, with the usual accompanying symptoms 
of prostration, delirium, stupor, and secondary affections of the pul- 
monary and gastro-intestinal systems. Daring the earlier periods of 
the fever, varying from five to nine days, the sounds of the heart, 
particularly the first, became enfeebled. In the more advanced stages 
of the abdominal cases, the first sound would become similar to the 
second, and grow feebler until the second alone was to be heard. In 
convalescence the first sound was again heard faintly; then it became 
similar to the second, and the action of the heart was restored with the 
inverse series of phenomena. 

In this epidemic wine does not seem to have been used by Professor 
Huss, but he gave tonics, such as the mineral acids, and nervine stim- 
ulants — musk, camphor, and so on ; and in the employment of these 



FIRST AND SECOND CARDIAC SOUNDS. 131 

remedies he acted on precisely the same principle that we adopt in the 
use of wine — that is to say, he was guided by the enfeebling of the 
first sound and impulse of the heart, and by the other signs of a 
depressed vital condition. 

There is one other point on which I have not touched — the existence 
and nature of cardiac murmurs in the advanced stages of fever. 
These are more frequently met with in the enteric or typhoid fever 
and in the relapsing forms of the disease than in maculated typhus, 
although even in the last-named they have been observed in the early 
stages of convalescence. Generally speaking they occur at the base 
of the heart, and are always systolic. In a few cases, however, they 
seem to be developed towards the apex, or they may occur in both 
situations at once. They are by no means so frequent or so prominent 
as in convalescence from rheumatic fever, in which we have observed 
them throughout the course of both the thoracic and the abdominal 
aorta. We need not here inquire whether they are anaemic or spa- 
nasrnic ; it is enough to know that they are not organic, and that they 
indicate the use of iron and a restorative treatment. In a few cases, 
but by no means in all, they are accompanied by venous murmurs in 
the neck. 

I was observing just now, in the ward, at the bedside of the boy who 
had the pulmonary lesion (I will not call it pneumonia), with a low 
typhoid fever (he is under the care of Mr. Daly), how well his case 
illustrates the advantage of clinical study. If you take up works 
upon disease of the heart, you find that it is assumed by almost every 
writer that the first and second sounds of the heart are to be easily 
distinguished from each other. There are some persons who, if you 
were to say to them, in any given case, "I have had considerable diffi- 
culty in saying which was the first and which the second sound of the 
heart," would set you down as very deficient indeed, and as one who 
had not been properly taught. But the fact is, gentlemen, that there 
are many cases in which at first it is very difficult indeed to say which 
is the first and which the second sound of the heart. Occasionally the 
most experienced man will require repeated observation before he can 
make up his mind. 

It has repeatedly happened to me that, after thinking I had settled 
the point, I was again thrown into doubt on moving the stethoscope 
an inch or two. 

I mention this to show you how diffident we should be in our 
opinions upon these subjects, how slow we should be to condemn 
men because they do not come up to the mark laid down in books. 



132 LECTURES ON FEVER. 

The truth, in fact, is, that they may go beyond it — that they are 
wiser than the authors of such books. 

There are two eases in which it is often extremely difficult to say 
which is the first and which the second sound of the heart. One 
of these is that triple combination of local disease which is so common, 
especially in private practice, where the patient has chronic bronchitis, 
a weak and irregular heart, and congestion and enlargement of the 
liver. But there is another element very commonly to be found in 
connection with this combination, and that is the gouty element; so 
that you may have a gouty man with chronic bronchitis, with a weak 
and irregular heart, and with an enlarged liver. In such a case it is 
sometimes extremely difficult to say which is the first and which the 
second sound. They are closely similar ; and the action is so irregular, 
so uncertain, that you may often apply the stethoscope for minutes 
together most carefully and yet not be able to make up your mind. 
This is one case. Well, take another — such as that of the boy above 
stairs. 

This boy presents some very curious phenomena ; and illustrates 
difficulties which you would not anticipate, if you depended merely 
upon the text-books for a diagnosis of disease of the heart. It is 
difficult to say whether the murmur which he has belongs to the first or 
to the second sound. But there is a greater and a still more impor- 
tant difficulty in this case — namely, to determine whether this is an 
organic or an ansemic murmur — and I am not ashamed to say that 
my own mind is not made up on the subject. It would be very easy 
to adopt one theory or the other, and to argue upon it ; but I know 
thoroughly the difficulties of the subject; and I think, at this moment, 
it would be hardly possible to say whether this boy has disease of the 
valves of his heart or not. There is one consideration connected with 
the case which is drawn, not from physical examination at all, but 
from the general history of the patient, and it is this, that while 
organic murmurs are rare — very rare in the form of disease which 
he has had — inorganic murmurs are comparatively common in it. 

This is a very strong point. We are here under this difficulty — a 
difficulty which you may meet with every day in private practice 
— that we are called on to give an opinion when the data that should 
guide us in that opinion are deficient. We want to know the pre- 
vious history of this boy. If, instead of being in hospital, he were 
a private patient under your care, or if you had been the attendant 
on his family for years together, were familiar with him and intimate 
with the state of his heart, you would be able to say, first, if he ever 
had carditis; next, whether, before his late attack, he had cardiac 



CARDIAC MURMURS. 133 

murmur or not. But we know nothing of all this; and the only fact 
we have to go on is the observation of Mr. Daly that when the boy 
was first examined this murmur was not there at all. I myself 
have no doubt as to the correctness of this observation of Mr. Daly, 
and believe that whether the murmur be organic or inorganic, it 
has been developed since the patient came into the house. Can 
we distinguish by acoustic signs alone, gentlemen — and this is a 
point which bears on the subject of fever in a most important man- 
ner — the inorganic from the organic murmur ? The answer to this 
question is simply that, in the present state of our knowledge, there are 
many cases in which we cannot do so; that there is no special acoustic 
character by which we can distinguish one of these phenomena from 
the other. This looks like a depreciating statement, as far as our skill 
in diagnosis is concerned; but the cause of diagnosis would be much 
more injured by attributing to it powers which it does not possess 
than by confessing its deficiencies. The diagnosis in the case in 
question is to be drawn from other sources — generally speaking, from 
circumstances connected with the condition of the patient, the absence 
of the signs of inflammation, and a variety of other points. 

As regards cardiac murmur in fever, the observation has been 
frequently made that valvular murmur, when the patient is made to sit 
up, does not disappear ; but we have found in this hospital that, in many 
cases in which a murmur was observed after fever, it was ascertained 
that, in an upright position, the abnormal sound disappeared, or, if it 
did not cease altogether, it became much less intense; so that the 
disappearance of the murmur in the upright position is in favour of its 
inorganic nature, while its persistence or aggravation points to an or- 
ganic origin. So far so well. But, you will ask, is this rule absolute ? 
This is a question which must be answered in the negative; for you will 
meet with anasmic murmurs which are not influenced by position; and 
I believe there are, on the other hand, organic murmurs which are 
influenced by position. There are, doubtless, some organic murmurs 
in which, when the heart is made to act rapidly, the murmur either 
disappears or becomes lost in the other cardiac sounds, so that you 
cannot distinguish it. 

My own impression about the patient whose case we are at present 
studying is that the murmur is inorganic. I trust it is; but I would 
not say so positively, because the sound, although strongly marked — ■ 
although approaching very closely indeed to the inorganic murmur — 
is similar to a kind of murmur which we in this hospital have met 
with in cases where the heart has been weakened. It is a true mus- 
cular murmur — a sound produced simply by the non-synchronous 



134 LECTURES ON FEVER. 

contraction of the muscular fibres — when they act vermicularl}', as it 
were. The murmur in our patient possesses more of this character 
than of that of the true valvular murmur. There is another point 
connected with it which is of importance. If this murmur was valvular, 
it would imply a great deal of disease; a rough, almost rasping bruit 
in the situation of the aortic valve, implies generally a great amount 
of disease, commonly chronic; and, under these circumstances, you 
might expect that the patient would show other signs of disease of 
the heart. So that we here have a diagnosis drawn, as I often ob- 
served to you before, from that important source — the want of ac- 
cordance of the symptoms. Supposing the murmur here to be 
organic, we should expect to find with this amount of valvular disease 
signs of dilatation of the left ventricle, or of the whole heart. And 
yet even when this boy had one of his lungs almost entirely 
obstructed — a condition which often acts in developing latent cardiac 
disease — the symptoms of cardiac suffering were not at all remarkable. 
So that there is here, to a great degree, this want of accordance in the 
symptoms — a condition which is against the opinion of the murmur 
being organic, and in favour of its being functional. A mistake, gen- 
tlemen, was often made in connection with auscultation generally — 
I am happy to say that it is but seldom made now — that of supposing 
that every disease had its special acoustic sign. Consequently the 
attention of students and physicians was directed to the study of 
physical signs from a purely mechanical point of view — to the 
observation merely of their acoustic characters. 

There can be no doubt that it is of the greatest importance to study 
carefully everything connected with a diseased organ — both its physical 
and its vital phenomena; but what you have to learn specially is not 
so much how to detect or recognize a particular sign, as to know how 
to reason upon it when you have discovered it. It is here that the 
clinical student of practical experience has the greatest superiority 
over the mere reader. His mind is trained to reason upon the phe- 
nomena which he observes. Here we have a group of phenomena; 
and if we did not give ourselves the trouble to turn every possible 
point of the case over in our minds, we should come to an imperfect 
and erroneous conclusion about it. 

Bear this in mind always, that there is no absolutely pathognomonic 
physical sign of any disease whatsoever. This cannot be too strongly 
stated; and I believe that we might go further, and say that there is no 
combination of mere physical signs which, excluding the history and 
vital symptoms, can be justly considered as pathognomonic; at all 
events, if there be such a combination, it is one of extreme rarity. We 



SECONDARY INTESTINAL COMPLICATIONS OF FEVER. 135 

hear of certain murmurs being pathognomonic of this and of that dis- 
ease of the heart — friction sounds being pathognomonic of pleurisy 
— crepitating rales, of pneumonia — amphoric sounds, of effusion of air 
and fluid into the pleura. All this is wrong; it is based upon 
error ; and you must expunge it altogether from your minds, if you 
wish to be good physicians and faithful observers of 



LECTURE XVIII. 

Secondary Intestinal Complications of Fevek — General and introductory remarks — 
A generic resemblance between tbe various forms of fever — Secondary abdominal 
complications are more frequently observed in typhoid fever, but do not exist as 
its necessary anatomical character — Dothinenteritis was largely prevalent in 
the typhus epidemic of 1826-28 — Fever must be observed independently in each 
epidemic and in every country — Typhoid fever almost without characteristic 
symptoms — Illustrative case ; extensive intestinal ulcerations found after death — 
Vital symptoms of intestinal complications: (1) thirst, (2) swelling of belly, 
(3) diarrhoea, (4) ileo-caecal tenderness, (5) increased action of abdominal aorta 
(6) rigidity of abdominal muscles — Three forms of abdominal swelling : (1) early 
and moderate tympany, (2) doughy condition, (3) slight ascites — Increased action of 
abdominal aorta — Case of, in perforation of the stomach — Analogous local arterial 
excitement in (1) whitlow, (2) rheumatism — Diagnosis from aneurism — Intestinal 
complications seem to interfere largely with action of the law of periodicity — Early 
alleviation of local irritation checks deposit, and so prevents future mischief — Hence 
relief of symptoms by early depletion as practised by Broussais, who misinterpret- 
ed the matter, and was led to look upon the general fever as but symptomatic of a 
local lesion. 

Gentlemen, I hope that none of you will misunderstand me and 
suppose that I do not recognize the differences between the various 
forms of fever, about which so much has been written in latter times by 
excellent observers. That a case of fever answering to the description 
of the pythogenic fever of Dr. Murchison — the typhoid of Sir William 
Jenner and Dr. Hudson — runs a different course from a maculated 
typhus or a relapsing synocha, is to be admitted. All these forms vary, 
whether in isolated cases or in the multiplied examples which occur 
in epidemics. As a rule they differ as to their apparent exciting 
causes, their local complications, their mortality, their attendant phe- 
nomena, and their consequent effects on the economy. That follicular 
disease of the intestines is commonly met with in typhoid as 
compared with typhus may be admitted, as well as the rule that the 
laws of periodicity in the former are not so well marked as in the 
latter. But what I want you to perceive is that there is between them 



136 LECTURES OX FEVER. 

a great generic resemblance. The greater your intimacy with fever — 
the more it is observed upon a large scale, the less attention you will 
pay in your diagnosis, prognosis, and treatment to the question 
whether the disease belongs to this or to that categorv. This is 
true at all events as to the typhus and typhoid fever. Much has been 
written to prove that dothinenteritis may be taken as the anatomical 
character of the latter disease, and some go so far as to deny the 
occurrence of ulceration of the intestine in maculated typhus. Yet no 
man who has observed this fever in an Irish hospital will subscribe 
to such a doctrine. Dothinenteritis is, or has been, a common occur- 
rence in the last-named form of the disease, its frequency and amount 
varying in different epidemics. In such a case are there two diseases, 
different in identity, existing together in the system ? and what becomes 
of the alleged differences, when the management of the case is con- 
sidered ? 

The theatre of a hospital is not the place for a systematic course of 
lectures. We can be here better employed, and the teacher's business 
is to say, like Mark Antony, " that which he knows," and to prove it by 
demonstration, referring to cases with which his hearers are familiar. 

When we consider fever in relation to pathological anatomy, symp- 
toms, exciting causes, and treatment, we find it a complex and ever- 
varying condition, with certain generic resemblances in the relations 
between it and the secondary affections which impress on it particular 
and varying characters ; but to lay down rules by which each type of 
fever can be proved to have a separate identity is to go too far. I have 
told you that no two epidemics are exactly alike either as regards their 
essential symptoms or local complications. The results of the most 
careful and extended researches will enable us to lay down principles 
— as to pathology, prognosis, and treatment — applicable when the 
disease occurs in different countries and climates and affects different 
races of men. 

I have said that this is not the place to go into the history of every 
observed form of fever, and into the various controversial questions 
that have arisen regarding them. Study the excellent works of Dr. 
Murchison, Dr. Hudson, Sir William Jenner, and Dr. Stewart, and use 
your own judgment as to how far your experience bears on the great 
questions therein discussed. In the mean time let us continue to study 
the local complications, after which we shall be in a position to deal 
with the question of the treatment, if not the prevention, of the 
disease. 

It will not be necessary after these observations to take up your time 
by going over the beaten ground of the pathological anatomy of the 



NO SPECIAL ANATOMICAL CHANGE. 137 

digestive tube in fever You will meet with descriptions of the tume- 
factions and ulcerations of the glands in every modern work on the 
subject. Let us rather take a general view of the symptoms attendant 
on fever with reference to the digestive system, and as we have studied 
the various conditions of the lungs and heart under the influence of 
the disease, let us now consider its secondary abdominal complications. 

What I have to say on this subject must be held to apply to the 
several varieties of fever. Although the symptoms now to be studied 
are not equally developed in all these varieties, yet when I speak of 
" local lesion " I intend my remarks to apply to fevers of every kind. 
We have spoken of the alleged anatomical distinction between 
typhus and typhoid — the one being free from intestinal disease, the 
other always presenting it. Now, it would be more philosophical, 
to say that no form of fever has any special anatomical change ; that 
where such does take place it is of a secondary character ; and that 
when it arises in the digestive system, it is more frequently observed 
in one form of fever than in another. Such a proposition might be 
accepted. 

The frequency of dothinenteritis as regards fever is, or has been, 
greater on the Continent than in this country. The typhoid is more 
common abroad than the true maculated typhus. Hence in proportion 
as true typhus is epidemic, we find fewer instances of the secondary 
intestinal lesion, which becomes more frequent when typhoid fever 
extensively prevails. But the local disease is not necessarily charac- 
teristic of any peculiar type of epidemic. In the outbreak of 1826-28 
(if ever there was a true typhus epidemic it was then) in a very 
large number of cases the secondary local disease of the intestine, con- 
sidered to belong to the typhoid form, was present. In fact, there 
was an observable tendency towards an extreme amount of disease of 
the digestive organs. It was in this epidemic that the yellow fever 
appeared, with peculiar symptoms of very severe gastro-intestinal 
disturbance. I cannot too earnestly impress on you all that, as re- 
gards fever and its treatment, you are not to trust implicitly to the 
statements of other observers, no matter how eminent they may be, 
in forming your judgment as to the cases at the time under your charge 
Recollect that all such statements are to be accepted only as bearing 
on outbreaks of fever as observed in different places and at different 
times; for both the locality and the period of an outbreak are con- 
siderations which must be taken into account. 

It was a grave medical error on the part of Broussais and his disci- 
ples to declare the constancy of gastro-enteritis over the world from 
observing fever in France. The same remark applies to theories as 



138 LECTURES ON FEVER. 

to symptoms and treatment — doctrines formed and adopted without 
reference to the period and place of observation and the prevailing 
epidemic character. You may admit the disease of the digestive organs 
to be met with less frequently in typhus than in typhoid, but if you 
were to conclude that in typhoid fever intestinal lesion was a special 
and constant result, or that it was not met with in typhus, you would 
be wrong. Eecollect what I have already told you as to the variable 
and inconstant characters of the local affections in fever. Cases of 
typhoid fever will come under observation wherein there is an 
absence of any direct symptom, or of any change whatever in the 
anatomical structure. This is an important fact, and a single case of 
the kind is of great value and interest. 

Again, we may have typhoid fever with intestinal lesion, but with- 
out any direct symptom beyond mere loss of appetite, and malaise — 
nay, even these symptoms may be absent. I will detail for you a re- 
markable instance of this. The disease ran a course of forty-three 
days without break or alteration. There were at first some slight 
respiratory symptoms, but subsequently the case seemed to be one 
of a purely nervous character. Towards the termination, symptoms 
of engorgement of the air passages and of weakness of the heart 
appeared. At no stage of the disease was there any swelling of the 
belly or tenderness there. There was no throbbing of the abdominal 
aorta, no rigidity of the recti muscles, no diarrhoea; the evacuations 
were all through healthy in character. In fact, so far as the belly 
was concerned, not a single symptom could be detected from beginning 
to end. I put the state of the tongue out of the question, as in fever 
it is no evidence of disease of the digestive system. Not only was 
there a complete absence of any direct symptom of intestinal disease 
in this perfectly marked case of typhoid, but also the patient took his 
food well and it seemed to perfectly agree with him. On dissection 
the lower third of the ileum showed a sheet of suppurating ulcers, 
with extensive destruction of the mucous membrane. 

The junior members of the class will learn from this case that in 
fever the symptoms of the secondary disease of the intestines may be 
singularly obscure, especially as compared with those in the lungs, 
heart, or brain, and when they do occur they do not give any reliable 
measure of the extent of disease. When the brain is affected, the 
nervous symptoms of pain, delirium, subsultus, coma, and so on, gen- 
erally reveal the disease. The disease of the lung, and especially of 
the heart in its softened condition, though partaking to a certain 
degree of the (so to speak) silence of the secondary affections, is ascer- 
tainable by physical examination — which in the lung discovers rale 



INTESTINAL AFFECTION PAINLESS. 139 

and dulness, and in the heart diminution or extinction of sound and 
impulse. 

Even the vital symptoms of these forms of disease often reveal the 
mischief. You may find dyspnoea, lividity, rapidity and feebleness of 
pulse, and so on ; but in the case of the digestive system matters are 
different. I think we owe to Broussais the knowledge of the fact 
that in fever inflammation and ulceration of the bowels may almost 
be described as a painless disease, the symptoms affording no reliable 
evidence as to the nature and extent of the local mischief. There 
may be thirst, some tympany, or moderate diarrhoea, and on dissection 
you may find ulceration, even having gone on to perforation — yet the 
symptoms of thirst, tympany, and diarrhoea will be insufficient to 
enable you to declare the amount of local disease. 

The most important vital symptoms, which all vary in their amount 
and intensity, are thirst, swelling of the belly, diarrhoea, and tenderness 
of the ileo-csecal region, and often of the epigastrium. Pain is rarely 
complained of. The abdominal muscles may be more or less rigid, 
and there is sometimes increased pulsation of the abdominal aorta. 

Three forms of abdominal swelling may be noted. You may find 
an early but moderate tympany affecting apparently the small rather 
than the large intestines. Again, especially in advanced cases, you 
may have a doughy-like condition of the belly yielding little or no 
tympanitic sound, and conveying to the hand a sensation as if the in- 
teguments were thickened and agglutinated to the organs beneath. 
I think I have observed another kind of swelling, caused by a 
slight liquid effusion into the peritoneum. This can be detected by 
the feeling of fluctuation when the patient is placed upright. Gen- 
erally, however, the abdominal swelling is principally tympanitic, 
while in some advanced cases the belly becomes collapsed. 

About the middle period of the disease you may often find diar- 
rhoea with or without morbid stools. The tenderness on pressure dif- 
fers from that of peritonitis in not being at all so well marked. This 
tenderness may be general, although most commonly it is best per- 
ceived in the ileo-csecal and epigastric regions. I would caution you, 
however, against using any but the gentlest pressure in seeking for 
this symptom ; the great rule in all examinations is to avoid giving 
the patient any cause of complaint or the least inconvenience. 

You are also to look for increased action of the abdominal aorta — 
an interesting symptom, of which the analogue maybe seen in the 
increased action of the radial artery in whitlow. I have observed that 
in this local manifestation of fever the pulsation of the vessel is often 
more equable than in ordinary nervous throbbing of the aorta. It 



140 LECTURES ON FEVER. 

disappears with the subsidence of the disease, and I have seen it do 
so after an application of leeches and poultices to the belly. 

In cases where its existence is doubtful we sometimes find a marked 
disproportion between the beat of the radial and femoral arteries. 
This is a very interesting subject, and the symptom in question led 
us some years ago to the diagnosis of rupture of the intestinal tube. 
A middle-aged man, who for more than a year had suffered from ab- 
dominal pains attributed to dyspepsia, fell down in the street, and was 
brought into our wards in a state of collapse. The surface was cold, 
and the pulse at the wrist had ceased. The belly was moderately full, 
but painless to pressure. 

These symptoms, connected with the previous abdominal pains, had 
all the characters of hemorrhage into the peritoneum from rupture of 
an aneurism. But we came to the conclusion that the case was one of 
perforation of the intestine from this circumstance — that while the 
pulse had ceased at the wrist, it-was distinct and jerking in the groin. 
The freedom from pain on pressure seemed to favour the diagnosis of 
rupture of an aneurism, but you must remember that the patient 
was in a state of extreme collapse. 

On dissection, the diagnosis of perforation of the digestive tube 
proved to have been correct. The solution of continuity was not, as 
we had supposed, in the small intestine, but in the great curvature of 
the stomach. The accident seemed to have occurred immediately 
after the man had taken a full meal, the ingesta having escaped almost 
wholly into the peritoneal cavity. The serous membrane presented 
a diffused red tinge, seen principally in the hypogastric region, appa- 
rently a very early stage of peritonitis, and as such sufficient to 
account for the increased local arterial action. 

While I am on this subject T may mention that iu certain cases of 
chronic aortic patency, with the usual arterial throb, in which the 
patient experiences an attack of rheumatic arthritis, say of the wrist, 
the force and vehemence of the corresponding radial artery become 
so exaggerated as to make it difficult to convey an adequate impres- 
sion of it. It may be compared to the blow of a steel hammer on an 
anvil — so greatly exaggerated by the local irritation is the ordinary 
increased impulse of the vessel. According as each joint becomes 
attacked under the influence of metastasis, the violent pulsation is 
found in the corresponding artery. I have known this temporarily 
intensified impulse, when its seat was the abdominal aorta, to lead to 
the wrong diagnosis of aneurism, the signs of which disappeared with 
the subsidence of the intestinal disorder. 

The diagnosis is to be drawn from the history of the case, as a 



SYMPTOMS OF INTESTINAL AFFECTION. 141 

violently acting abdominal aneurism is not developed in a short period 
of time without previous symptoms. The combination of abdominal 
aneurism with permanent patency of the aortic valves is rare indeed, 
and the existence even of a large aneurism has little if any influence 
on the action of the vessel above and below it. Constitutional dis- 
turbance resulting from the local irritation also aids the diagnosis, for 
there is nothing more remarkable than the long preservation of the 
general health in a case even of large abdominal aneurism. 

In enteric fever you may often find a rigid state of the muscles of 
the belly. It seems principally to affect the recti muscles and, I think, 
preponderates at the right side. It may vary from day to day, and 
apparently corresponds with the phases of the local malady. How far 
this condition is related to the signs of gurgling in the ileo-csecal region 
may be questioned. But this latter sign, unless when plainly localized, 
is not of great value. 

As to the state of the tongue, you cannot in a case of fever place 
much, if any, dependence on it as a measure of intestinal secondary 
disease; you are to look on it as an index less of the local than of 
the essential malady. The morbidly clean, bright red, and glazed 
tongue may change and assume a natural appearance under strong 
stimulation. 

Looking at the secondary disease of the intestine and its liability to 
reactive inflammation, I think it probable that it interferes more with 
the periodic laws of fever than do the respiratory affections, and many 
cases of protracted fever may be thus looked on as examples of an 
essential combined with a symptomatic condition — the first causing 
the special deposit, and the second resulting from the reactive irrita- 
tion which may terminate in ulceration, or suppuration, and thus sus- 
pend the action of the law of periodicity. Hence the sooner we can 
detect and alleviate the local irritation the less will be the deposit, and 
the less also will be the interference with the periodic laws. The 
amount of deposit in essential disease, as we see in variola, seems to 
be influenced by that of the cutaneous vascularity and irritation. By 
early local depletion we can greatly diminish the degree of pustulation 
and its virulence. In fact, its occurrence in particular situations, say 
the face, can be all but suspended. 

Now, this point was never considered by the school of Broussais, or 
they misinterpreted the mutter. A patient had fever, and the appli- 
cation of leeches to the belly was followed by great relief of symp- 
toms, and soon by the subsidence of the fever. Here, they said, is a 
proof that the fever was only symptomatic of the gastro-enteritis, and 
so the idea of essentiality must be given up. No, say the more careful 



142 LECTURES ON FEVER. 

observers; the relief in this case is from the diminution of a secondary 
reactive irritation interfering with the law of periodicity, which was 
again permitted to act on the removal or modification of that irrita- 
tion. 

You cannot sufficiently study in fever the relations between its 
secondary and its essential conditions, or the influence which the latter 
have on the former when a process of reactive local inflammation is 
set up, giving rise to symptomatic irritation, and interfering with 
the periodic laws. In some cases of enteric fever these laws are 
permitted to act, and an abortive attempt at recovery takes place. 
In those described by Dr. Cheyne in the "Dublin Hospital Reports" 
the general characters of fever subsided, the pulse fell, and appetite 
returned ; but after a time symptoms of intestinal disease became 
developed, and the patient sank after the false crisis with extensive 
disease of the mucous membrane. It was suggested by Dr. Todd that 
in such cases a state of pyasmia was induced by the absorption of pus 
from the intestinal ulcers; but the symptoms in the second stage of 
Dr. Cheyne's cases were more likely due to irritation of the intestine, 
which interfered with the retrocession of the secondary disease and 
prevented crisis. No doubt in abdominal typhus you may find the 
mesenteric glands filled with pus, but in fever, as in variola, there 
seems to exist a power of disposing of purulent secretion in vast 
quantities, which if retained would act as a poison. 



LECTURE XIX. 

Intestinal Complications of Fever, continued — They resemble all the other secondary 
affections of fever in their general characteristics and relations to the primary 
essential malady — More frequent in typhoid, but occurring in typhus also, as, for 
example, in the epidemic of 1826-27 — Pathological appearances observed in the 
intestinal tract in that fever — Yet these appearances were not necessarily found 
after death even where sever* abdominal symptoms existed in life — Eruption of rose 
spots in fever. 

When we review the lesions of the abdominal organs in fever, we 
find that in their relation to the essential malady they are subject to the 
same general laws which govern the other secondary affections. They 
are — and it cannot be repeated too often — not the cause, but the result 
of the essential disease, whether that exists in the form of bad typhus 
or of enteric fever. They are various in their amount and intensity, 



fever of 1826-27. 143 

and this so remarkably that even when looked on as secondary affec- 
tions they fail to furnish an anatomical expression for the malady. 
The vital symptoms of the local affection are rarely prominent, so 
that the attention of the physician may never be called to them by 
the patient. This is more especially the case in proportion as the 
fever partakes of the characters of typhus rather than of typhoid. 

But we cannot predicate in any given case or in any epidemic 
under what conditions or in what degrees the local affection may 
present itself, how far it will modify the general symptoms, or what 
other seats of secondary lesion the case may exhibit. 

In the great epidemic of 1826 and 1827 the disease, as I have told 
you, was clearly a typhus fever, with every character of the affection. 
It was highly contagious, with abundant and well-marked petechial 
eruption and prominent secondary affections of both the respiratory 
and digestive systems. The tumefaction and ulcerations of the ileum 
were found well marked in numerous cases, so that if those who advo- 
cate the doctrine that such a lesion does not occur in typhus had been 
here at the time, and had made dissections in this hospital, they would 
never have defended this opinion. Let me again impress upon you 
that the very occurrence, or amount, or intensity of this or that secon- 
dary affection in fever varies according to the epidemic. In this fever 
we had all the anatomical characters of the intestinal disease — the 
tumefaction of the mucous glands, their vascularity and ulceration; 
the filling of the mesenteric lymphatics with pus, and its deposit in the 
mesenteric glands; sloughing of the glands of the intestines, and so 
on. You must be careful not to infer the symptoms and the anatom- 
ical results of disease from the observations of a single epidemic. 

Discard altogether the idea which has been put forward by many 
persons who make too fine distinctions in medicine that this disease, 
of which I have given you now a rough sketch, is, or has in itself, any 
great value as an anatomical distinction between different kinds of 
fever. This is a favourite doctrine of those writers who hold that 
there is an essential difference — a complete difference — between the 
typhus fever of these countries and the fever of the Continent. The 
real state of the case is that, although this complication is more fre- 
quently met with on the Continent than it is here, it is not infrequently 
met with here also. It is also true that, although it belongs more to 
the non-petechial cases than to the petechial, yet it may occur in the 
latter and it may be absent in the former. 

The tendency to this affection varies greatly with the epidemic 
character of the disease. In one year we may have extremely well- 
marked petechial typhus without the slightest appearance of ulcer- 



144 LECTURES ON FEVER. 

ation or disease of the mucous membrane of the intestine — and if one 
who advocated the doctrines I spoke of came to this county and made 
his dissections during that period, he would probably find abundant 
cases to establish his doctrine. But it might happen that if he re- 
turned after a few years he would find occasion to change his opinion, 
for he would then see a fever in all its external characters the same 
that he had seen before — a fever with true petechia and all the 
characters of essentiality — but, further, a fever with the intestine 
extensively ulcerated. It is incorrect, then, to say typhus fever may 
not be attended with this anatomical change in the intestine ; this I 
wish strongly to impress upon you. The occurrence of it is, so far as 
we know, accidental ; at all events, it is not a necessary consequence 
either of the non-petechial or of the petechial fever; but in some 
epidemics we may have petechial fever with it. And, again, even in 
the same epidemic we may have cases with the whole intestinal tract 
perfectly free from disease, and also cases in which it exhibits the 
affection extensively. 

Now, in illustration of this I will read the particulars of some 
dissections of fever which were observed in the epidemic of 1826 and 
1827. I have stated that this was a very singular epidemic, and one 
which, apparently, is unknown to the Continental writers. It was a 
very extensive and prevalent outbreak ; it infected many hundreds of 
thousands of persons in this country. I think there were something 
like 3000 beds for fever open in Dublin, and I am quite sure that if 
there had been 10,000 beds, they would have been all filled. There 
were in this hospital alone 300 beds, so that we had a very good op- 
portunity of observing it. It was a true typhus fever, a maculated 
fever — this I wish to impress strongly upon you — and yet in a very 
large number of cases indeed there was follicular disease of the intes- 
tine. Now, such is the state of prejudice on this subject on the Con- 
tinent and elsewhere, that when you mention such a simple fact as 
that we had in this country an epidemic of typhus fever — of maculated 
fever with ulceration of the intestine — a large number of the best 
informed Continental pathologists will shrug their shoulders and 
politely express a doubt as to the fact that you have told them. 

But in order to show the great variety presented by the secondary 
intestinal affections in one epid'emic, I will briefly describe the patho- 
logical conditions observed. 

The most usual appearances were extensive ulcerations in the lower 
third of the ileum. These ulcers were either isolated and circular — 
as large as a sixpence, with raised edges and very deep — or running 
all around the intestinal tube. There was also great enlargement of 



ERUPTION OF ROSE SPOTS. 145 

the lymphatics of the mesentery — the vessels containing purulent fluid, 
and the mesenteric glands themselves in a state of suppuration and 
destroyed. These were the common anatomical changes as far as the 
abdomen was concerned. There were also, in a large number of 
cases, typhous affections of the bronchial system. The bronchial and 
the intestinal tracts were the two points on which the force of the 
secondary affections of the disease seemed to be thrown. But in this 
very epidemic other cases occurred in which ulcers of the intestine 
were not found, and yet the disease was fatal, and fatal with abdomi- 
nal symptoms. This was seen in those terrible cases of yellow fever 
which I shall presently describe. So that here we find a general ten- 
dency to secondary abdominal affections, but a variation in their 
nature ; and if this be true, what becomes of the special anatomical 
character of the fever? 

You will not forget that with regard to the symptoms of disease of 
the mucous membrane and glands in fever, and especially in that form 
called typhoid, enteric, or pythogenic fever, or abdominal typhus, 
though these symptoms are more often present, yet the absence of 
one or many of them is not uncommon. Much attention has been 
paid by various observers to the eruption of rose spots, supposed to 
be peculiar to typhoid fever. Although we do not know anything of 
the rationale of this symptom, its frequency must be admitted. But, 
as regards its appearance, the condition of inconstancy must also be 
admitted, nor is its existence to be taken alone as a clear distinction 
between fever with, and fever without, the intestinal affection. Like 
all the other local symptoms of continued fever, it is not constant in 
its occurrence, its amount, its successive appearances, its relation to 
the stage of the disease, its complication with other cutaneous erup- 
tions — measly eruptions or petechias, or its connection with symptoms 
of progression or renewal of the abdominal lesion. In the course of a 
protracted fever three or more distinct eruptions of rose spots may 
take place and you may observe the latter ones even when the con- 
stitutional state and local symptoms of fever have nearly if not alto- 
gether subsided. 



10 



146 LECTURES ON FEVER. 



LECTURE XX. 

Intestinal Complications of Fevek, continued— Division into three categories, with 
reference to the vital symptoms : I. These symptoms are absent, although the silent 
disease may be great in amount ; II. Local symptoms are evident ; III. Symptoms 
and pathological changes are both well marked— Further description of the epi- 
demic of 1826-27— Sudden access of intense abdominal pain, followed by icterus 
and gangrene— Fatality of this complication— Splenic(?) abscess occurring in the 
first case of recovery, and discharging through the lung— Resemblance of this form 
of fever to the yellow fever of the tropics— Dr. Lawrence's observations— Dr. Graves' 
observations. 

With reference to the vital symptoms, we divide cases of fever 
with abdominal secondary complication into three categories. 

In the first it may be said that the local disease is silent — although, 
us in a case I detailed to you, its amount be great, no direct local 
symptoms exist, and the patient does not draw your attention to it. 
This may occur in petechial or in non-petechial fevers, or, to use 
another expression, in typhus or in typhoid. The amount of the so- 
called characteristic affection varies in different cases and different 
epidemics from a very few small ulcers to extensive disease and de- 
struction of tissue. 

In the second category there are evident local symptoms, such as 
early tympany, tenderness on pressure, arterial throbbing, diarrhoea, 
and rigidity of the recti muscles. These symptoms may occur in both 
forms of the disease, but are more common in non-petechial than in 
petechial fevers. 

In the third category we place those cases observed in the epidemic 
of 1826-27, in which the abdominal complication widely differed in 
the violence of the symptoms and in the pathological changes from 
anything we had seen before or have seen since. 

In this third class abdominal complication is attended with mani- 
fest and violent symptoms, the nature of the affection in many respects 
differing from the ordinary dothinenteritis in typhoid, and even as it 
occasionally occurs in typhus. 

In the epidemic of 1826 and 1827, as I have said, the secondary 
affections were often marked by a great activity and severity. I 
have spoken to you before of this epidemic, but it is a remarkable 
circumstance that while the follicular disease of the intestine was 



YULLOW FEVER OF 1826-27. 147 

extremely frequent throughout its course, yet in the particular group 
of cases of which I am now about to speak it was absent. 

In the course of this epidemic the following extraordinary circum- 
stance occurred : Patients who had precisely the symptoms of the 
general fever — whose symptoms presented nothing to draw particular 
attention to them more than to others — would be suddenly seized 
about the seventh day with extraordinary abdominal spasms — the 
spasms so severe that they could be likened only to the worst cases of 
painters' colic. In some cases the pain was so great as to make the 
patient scream out, and, just like the spasms in painters' colic, there 
was great relief given to the patient by making strong pressure upon 
the abdomen. In the course of a very short space of time — I believe 
within an hour or less — it was observed that the patient's face began 
to turn yellow. A jaundiced tint rapidly spread over the whole 
body, so that on the day on which the patient was attacked he was 
universally jaundiced. The kind of jaundice was curious too. It 
never amounted to the extreme degree of yellowness seen in true 
jaundice. The patient was very yellow certainly, but he had not that 
intense yellowness which you see in cases of mechanical obstruction 
of the gall ducts, or of cancer of the liver, and so on. 

The horrible spasms continued for several hours. The patient then 
began to vomit black matter — matter at first like coffee grounds, but 
afterwards quite black. In a few instances he passed the same matter 
from his bowels, but in most cases the bowels were constipated. Then 
began another class of symptoms. The tip of the nose grew cold ; 
it became pale, livid, purple. The same appearance was presented by 
the toes. A gangrene — true gangrene — of the uares and of the toes 
preceded death. In some cases death took place with the whole of 
these symptoms within six hours from the invasion of the attack of 
spasms; in others the patients lived for twenty-four or thirty-six 
hours. I believe few lived for more than thirty-six hours. 

This disease attacked the finest and best developed men ; young 
men from twenty-five to thirty years of age were very commonly 
struck down. The first sixteen of these cases died ; not one was 
saved. The outbreak excited the greatest possible consternation ; it 
was thought that the yellow fever was about to break out in these 
countries. 

The post-mortem appearances in these patients were the same in all, 
and they were different — remarkably different — from those in other 
patients who died in this epidemic, but without these symptoms. In 
these cases we did not find follicular ulcers of the intestine. It is a 
very curious fact that the so-called anatomical character of typhoid 



148 LECTURES ON FEVER. 

according to many writers, was not here. What did we find ? We 
found in the first place that the peritoneum was not inflamed, notwith- 
standing the dreadful pain. It had just the appearance that we see in 
many cases of bad fever— a certain lividity of colour. In every dis- 
section we found intussusceptions to the most extraordinary extent, 
invaginations of the intestiues in every direction upwards and down- 
wards ; in some patients as many as six were observed. In all of 
them there was an enormously enlarged spleen, in a condition of ex- 
treme softening, so that in some patients it was difficult to take this 
viscus out of the body without rupturing it. In none, however, did 
it appear that actual rupture of the spleen had occurred during life. 
In none did we find any inflammation of the liver, and with respect 
to the mucous membrane of the stomach and of the intestines, all 
that can be said was that there was extreme lividity and softening in 
different portions of the intestine. Now I mention this fact particu- 
larly, to show that in an epidemic of our. typhus fever where there is 
a tendency to abdominal symptoms we may have essentially different 
anatomical results. 

I have told you that in none of these cases was the liver inflamed, 
and the close similarity of the anatomical appearances with those ob- 
served in the yellow fever in the Southern States of North America 
is very remarkable. An American physician, Dr. Lawrence, has 
published a series of dissections in cases of yellow fever, which 
exactly correspond to the post-mortem appearances in the outbreak I 
have described. I believe that inflammation of the liver is rarely 
observed in the yellow fever of tropical climates; and this is also true 
of the fever we experienced here in 1827. 

But while dwelling on this subject, I may mention that the seven- 
teenth patient was the first to recover. I do not say that his recovery 
was owing to the treatment adopted. It is more likely that it was due 
to the decreasing violence of the morbific cause; for in every great 
and extraordinary epidemic the first cases, generally speaking, are the 
most violent, and it is probable that the result of this seventeenth case 
was owing mainly to the fact that the intensity of the disease was on 
the decline. Afterwards others recovered, and the disease lost a great 
deal of its violent character. 

One patient made a good recovery even after having lost the left ala 
nasi and one of her toes; but in the case just spoken of the following 
circumstances occurred— and it is interesting to note them in connec- 
tion with the question of yellow fever generally. The patient was 
treated on this plan : He was allowed wine with extreme liberality. 
Sixteen leeches were applied to the epigastrium. He also used mer- 



CASE OF ABDOMINAL ABSCESS. 149 

cury and opium freely and after a time left the hospital to all appear- 
ances perfectly well. In the course of about two weeks he expressed 
a great desire to be readmitted into the hospital, stating that he was 
very ill: 

On readmission he looked miserable. His respiration was very 
quick ; he had a dry cough and a rapid, small pulse, with severe 
sweating at night ; and he presented all the appearances of n person 
in acute phthisis. Upon a careful examination, however, we were 
surprised to find that there were little or no stethoscopic signs of dis- 
ease of the lung. The chest everywhere sounded well, and there was 
hardly any rale to be found; a little sibilant rale here and there 
might be discovered. I may mention to such of you as have, not 
studied the subject of acute tubercle following fever, that in almost 
all instances of this affection there are intense signs of pulmonary irri- 
tation. In the present case the absence of these signs led us, after a 
day or two, to doubt that the patient was getting tubercle, as we had 
at first supposed. I repeatedly examined him with extreme care over 
the whole chest. One morning I found nothing; next day, upon 
entering the ward, I saw the patient sitting up in a state of orthopnoea 
with a large vessel beside him completely filled with pus. There 
were, I am sure, three pints of purulent matter in the vessel. Upon 
examination I found an extraordinary change. While his chest had 
been quite clear the day before, the entire of the left side posteri- 
orly was now absolutely dull; there was no resonance of the voice or 
tubular breathing on this side. 

The patient gradually recovered, and the whole progress of the case 
indicated that an abscess had formed and had opened through the left 
lung. Whether it was a case of actual communication between an 
abdominal abscess and the lung, with escape of the pus into the latter; 
or whether it was one of those extraordinary cases of vicarious action 
of the lung relieving the abscess, is a matter we cannot tell, for the 
patient recovered and lived afterwards for many years in perfect 
health. 

For a long time I was in the habit of looking at this ease as an 
exceptional one in the epidemic, in which, you may remember, we 
did not find any example of acute hepatitis. I have since come to 
the conclusion that the case was, in all probability, abscess of the 
spleen. You will recollect that enlargement and softening of the 
spleen were constantly present, and this may be held to have pre 
pared the organ for suppuration after convalcsence from the f j ver. 

Recollecting also that the sudden flow of pus took place through 
the left lung, it seems most probable that splenic abscess formed,, 



150 LECTURES ON FEVER. 

which perforated the diaphragm, crossed the pleura by means of ad- 
hesions, and was finally discharged into the lung. It is possible that 
when the patient came into hospital the second time the spleen was a 
mere sac of purulent matter, and hence its condition would more 
easily have escaped detection from the fluid character of its contents. 
A case has been placed on record of abscess of the spleen in fever in 
which, although perforation into the lung did not take place, such an 
accident would have occurred had the patient survived a few days 
longer ; for the part of the diaphragm in contiguity to the abscess 
was found nearly penetrated. 

It is possible that this diseased condition of the spleen began to be 
developed during the acute stage of the fever; and taking into ac- 
count the peculiar character of the epidemic, distinguished as it was 
by extreme activity of all the organic processes; it is most likely that 
the spleen passed from the softening into the suppurative condition 
during the patient's convalescence. Dr. Hudson, in speaking of the 
vomiting which so often occurs in relapsing fever, mentions a re- 
markable case reported by Dr. Law. In the course of less than two 
days the patient passed from a slightly jaundiced hue into deep jaun- 
dice, with delirium, lethargy, coma, and death. The liver and spleen 
were found much enlarged and congested, and so softened that they 
seemed as if they had been soaked in blood. May we not suppose 
that, if life had been prolonged, such a condition of these viscera would 
have ended in suppuration and the formation of abscess ? 

The case which I have described above was the only one in which 
suppuration of a large viscus came under our notice in convalescence 
from this fever, but it is an interesting fact that a very few years sub 
sequent to this epidemic the occurrence of hepatic abscess was fre- 
quently noticed in this hospital, and, indeed, in most of the hospitals 
in Dublin. This you will see from a report, by Dr. Graves and 
myself, in the fifth volume of the " Dublin Hospital Reports." 

With regard to the identity of these extraordinary cases of fever 
with the yellow fever of tropical climates, you will remember that I 
spoke of the dissections made by Dr. Lawrence, of America, and the 
close correspondence of his results with ours. Without entering at 
length into the question, which is fully discussed by Dr. Graves in 
his twenty-first lecture, I will merely say that in my own opinion 
the view taken by him is correct — namely, that the diseases differ 
only in degree. Certain it is that the most prominent symptoms of 
the tropical yellow fever were present in the outbreak which occurred 
here — black vomiting, epigastric tenderness, jaundice, and enlarge- 
. ment of the spleen. 



INTESTINAL COMPLICATIONS OF FEVER. 151 



LECTURE XXI. 

Intestinal Complications op Fever, continued — Organic changes— Perforation of 
intestine — Of common occurrence in 1826-29 : (1) Generally rapidly followed by 
symptoms of peritonitis ; (2) hut may be unattended by local symptoms in pro- 
gressive cases, or again may induce only limited peritonitis (adhesions) ; (3) 
Symptoms of perforation may be veiled by the co-existence of intense irritation 
in another cavity of the body — Illustrative case — Time of occurrence of perforation 
as observed in six cases — Diagnosis of internal solutions of continuity is based on 
sudden development, without apparent exciting cause, of new, local, violent, and 
often rapidly fatal symptoms — Cases to which this rule of diagnosis is applicable — 
In effusion into a serous sac the degree of resulting inflammation is determined 
chiefly by the quality of the effused fluid — Examples — Influence of an irruption 
of pus in producing serous inflammation contrasted with that of an irruption of 
blood — Physiological difference between pus corpuscle and white blood cell — The 
formation of conservative adhesions seems to be rarer in peritonitis than in 
pleuritis — Case of hepatic abscess in which adhesions occurred and recovery 
followed (diagnosis from abdominal aneurism). 

We have to-day to study another of the results of abdominal 
complication in fever, where the ulcerative process in the mucous 
glands of the intestine goes on to perforation of the tube, generally 
resulting in effusion of its contents into the peritoneal sac. You are 
not, however, to suppose that this ulceration in all cases is the result 
of an attack of fever — it may arise under other circumstances. 

Still the follicular ulceration in fever is more likely to induce per- 
foration than other forms of this affection. You all know how common 
ulceration of the mucous membranes is in phthisis with diarrhoea, yet 
how very rarely do we meet with perforation in this case ? 

I have spoken of the epidemic of 1826 and 1829 as being remark- 
able for the activity of the secondary organic changes. At the close 
of this epidemic we had several cases of perforation of the intestine 
in our wards, though before and since that time this accident has 
been rarely observed. You will see reports of these cases in the fifth 
volume of the "Dublin Hospital Reports" 

Thus, in a large proportion of the cases observed by Dr. Graves and 
myself, the symptoms were those of a sudden and violent attack of 
peritonitis, which proved rapidly fatal, so that there was little difficulty 
as to the diagnosis. 

But, as in other internal solutions of continuity, there may be latency 
as regards the accident. Perforation by no means implies escape of the 



152 LECTURES ON FEVER. 

contents of the tube into the peritoneal sac, and little or no local 
symptoms may attend the progressive ulceration — as in the case I 
mentioned to yon. 1 In this way several perforations may occur with- 
out general peritonitis. 

In other cases the inflammation of the serous membrane seems to 
be limited to the seat of the lesion, where the contiguous folds of the 
intestine become agglutinated by adhesion, which thus prevents the 
escape of the faecal matter and the production of sudden and general 
peritonitis. 

But there is a third class of cases, in which the latency of even an 
extensive amount of peritonitis attending the perforation, seems to be 
owing to the coexistence of intense irritation in another cavity of the 
body. A young woman was admitted with fever and severe secondary 
bronchial affection. In the course of five days she had some epigas- 
tric pain, which was removed by leeching. The belly became some- 
what tympanitic, and the condition of the lungs got worse. The fever 
ran on, and in about nine days symptoms and signs of pneumonia 
appeared in the left lung, with tenderness of the epigastrium, for which 
she was again Keched over this region and also on the left side. Tar- 
tar emetic was ordered, and in a few days the pneumonia seemed to 
subside, but recurred. The skin then became cool, and we had hopes 
of her recovery ; but the thoracic symptoms returned with violence, 
and she died after an illness of about three weeks' duration. 

This was a case of tubercular fever combined with dothinenteritis. 
The substance of the lung was of a bright vermilion colour, perfectly 
fluffed with recent miliary and granular tubercles, and with intense 
redness of the bronchial membrane. Some puriform fluid was found 
in the peritoneum, and the small intestines were generally glued to- 
gether by soft exudation, which, on being removed, allowed us to see 
no less than four perforations capable of admitting a quill in the lower 
portion of the ileum. Many of the follicular glands were enlarged, 
and — in the lower portion of the gut — ulcerated in different degrees, 
so that in some the bottom of the ulcer was the muscular, while in 
others it was merely the serous, coat. In the arch of the colon were 
two small ulcerations. No faecal matter appeared to have escaped 
through the perforations. 

This case shows how the symptoms of a severe affection in one 
cavity may be masked by the existence of violent irritation in another. 
You may see something of the same kind in delirium tremens from 
excess, which may be complicated with a group of local irritations of 

1 Page 138. 



INTESTINAL PERFORATION. 153 

the heart, lungs, stomach, and brain, no one of which diseases pre- 
sents the usual prominent local symptoms. 

It is interesting to inquire respecting the period of the fever at 
which the perforation and consequent fatal peritonitis take place, for 
by this we may learn something as to the rapidity of intestinal ulcer- 
ations. You are to remember that our cases occurred at the time 
when the epidemic was dying out, and we may hold that the activity 
of the organic process for which it was so remarkable was on the 
decline. 

In our first case — that of a man aged 36 — the symptoms resembled 
those of ileus: great pain, violent spasms of the abdominal muscles, 
and tympanites. These set in on the seventh day ; great aggravation 
of pain took place on the eighth, and he died on the thirteenth day. 
A perforating ulcer capable of admitting the finger was found about 
three inches above the ileo-caecal valve ; the mucous membrane above 
and below the valve was intensely red and softened ; the bladder was 
inflamed — inability to pass water, which yielded to treatment, having 
been amongst the early symptoms. 

In the second case — that of a man aged 32 — violent pain followed 
a severe debauch. It returned in the course of two days, having been 
at first relieved by purgatives. On the return of the pain, though the 
belly was swelled, it was not very tender on pressure. The pulse was 
full and the bowels obstinately costive. In consultation with the late 
Dr. Beauchamp, bleeding, purgatives, and injections were ordered, the 
pulse continuing full and strong. During the night excruciating pain 
came on, with green vomiting, and the man died next morning. 

A perforation was found in the last twelve inches of the ileum, 
corresponding with a follicular ulceration. Many similar but non- 
perforating ulcerations were found. 

In the case of tuberculous fever which I have just now related it is 
impossible to fix the time of the perforation, but you will remember 
that there was no escape of feculent matter into the peritoneum. It 
would seem that a mere perforation not followed by this occurrence 
is, like the ulceration of the mucous membrane, a silent process as far 
as relates to pain. 

In another case of perforation the accident seemed to occur on the 
fifth day. The patient had headache, for which he took two doses of 
epsom salts, by each of which he was briskly purged. On the fifth day 
violent pain, prostration, and vomiting came on. He was at once 
admitted with fecal vomiting, collapse and pain, and tenderness of 
the abdomen. He died on the sixth day, all pain and tenderness of the 
abdomen having dissappeared for many hours hfore death. The usual 



154 LECTURES ON FEVER. 

appearances of perforating ulcer, general peritonitis, and disease of 
the mucous glands of the ileum were found. 

In our fifth case, which was a mild enteric fever with epigastric 
tenderness, the countenance became anxious on the thirteenth day, 
the tongue glazed and dry, and the patient, a man aged 21, complained 
of pain in the belly. Soon afterwards hemorrhage from the bowels 
showed itself, and the abdominal pain became intense. Next day he 
had all the symptoms of severe peritonitis, and he died the following 
morning. The peritoneal cavity was filled with sero-purulent matter. 
About two inches from the ileo-csecal valve an open perforation was 
found, and the mucous glands in its vicinity were in various stages of 
ulceration. 

The last case I shall notice was that of a man aged 46, who a year 
previously had contracted ague. The paroxysms were stopped by 
bark, but thirst, anorexia, soreness in the epigastrium, and yellow 
slimy dejections continued. Twelve days before admission he was 
attacked by shivering, followed by vomiting and severe pain about 
the umbilical region. A bilious diarrhoea succeeded, which lasted for 
ten days ; then it ceased, and the pain became suddenly intense, with 
retention of urine. The belly swelled, and the pain and tenderness 
were general. He sank on the third day after admission. 

The peritoneal cavity being opened, a rush of foetid air took place, 
the sac being found to contain much yellow fluid mixed with fsecal 
matter and lymph ; a thin false membrane covered the peritoneum of 
the liver and the abdominal parietes. The small intestines were livid 
and covered with coagulable lymph. 

One more example of perforation without effusion of the contents 
of the tube, and consequent fatal peritonitis, has been observed in our 
wards. Here the perforation appeared to be closed by merely the 
serous membrane of the contiguous fold of intestine, which was not ad- 
herent, and which showed only a slight patch of lividity. Do not forget 
this, as it illustrates the importance in these cases of seeking to lessen the 
peristaltic action of the intestine. When I speak of treatment we shall 
return to this subject. 

The diagnosis of internal solutions of continuity is based upon the 
occurrence of sudden, perfectly new, local, violent, and in many cases 
rapidly fatal symptoms, all this often happening without manifest ex- 
citing cause. The violence of the symptoms seems to depend on 
changes in the mechanical state of organs, on the production of acute 
local inflammatory action, and on internal losses of blood, causing 
syncope with or without convulsions. Here the embolic pathology 
confirms principles already in use so far as the solids are concerned, 



INTESTINAL PERFORATION. 155 

and extends their application to the fluids ; for there is in one sense 
a solution of continuity, not indeed of the, tissues of the suffering 
organ, but in the current of the fluids which supply it. 

The same general rules of diagnosis apply to many different cases, 
such as rupture of the heart or of an internal aneurism ; perforation 
of the pulmonary serous membrane from the lung ; opening of an 
empyema into the lung, causing expectoration of pus and pneumo- 
thorax ; perforating ulcer of any portion of the digestive tube; rup- 
ture of the urinary bladder, uterus, or gall-bladder; the opening of an 
abscess of the liver into the peritoneum, pleura, or pericardium : and 
rupture of a vessel in the brain. 

The cases of peritonitis from perforation we have been considering 
are examples of an acute local inflammatory action, the result of a solu- 
tion of continuity. 

Now, as regards the diagnosis from sudden inflammation of the 
perforated organ, much depends on the quality of the fluid which 
escapes into the sac. The effusion of the contents of the intestinal 
tube, urinary bladder, or gall bladder, is commonly attended with new 
and violent inflammation ; while more bland fluids, such as blood or 
the contents of an hydatid sac, do not produce these violent effects. 
The sudden effusion of purulent matter, on the other hand, is often 
followed by intense inflammation of a serous sac — as we see in phthisis 
with pulmonary fistula, and in hepatic abscess opening into the peri- 
toneum. 

Of this latter accident we had a remarkable example in our wards 
many years ago. It occurred in 1828, when abscess of the liver was 
observed in many instances. The early symptoms of hepatic irritation 
were rather obscure, but three weeks before admission the patient had 
sweatings and nocturnal perspirations. The right side was dilated, 
but the intercostal spaces were well marked. There were all the signs 
of hepatic tumour. In the course of a fortnight the swelling increased, 
and as the symptoms indicated abscess, although there was no fluctu- 
ation, Dr. Graves' operation was performed. In the course of a week 
a fluctuating tumour appeared between the median line at the epigas- 
trium and the lower end of the wound. The patient was greatly 
prostrated. A lancet was pushed from the wound into the tumour, 
when in place of the expected matter there was an effusion of dark 
bile. No jaundice existed at the time. The circumscribed tumour 
subsided, but the fulness of the side remained. In the course of four 
hours the patient had two very copious motions, consisting of purulent 
matter tinged with bilious and fluid feces. It was plain that the ab- 
scess had opened into the intestine. Next morning the improvement 



156 LECTURES ON FEVER. 

was remarkable: the swelling had much diminished, and in a few 
days had altogether subsided. The patient improved so much as to 
take exercise, but continued to be affected with an obstinate diarrhoea. 

In little more than three weeks from the subsidence of the tumour 
a small hard swelling appeared in the epigastrium : it rapidly increased 
and became fluctuating. The diarrhoea continued. Thirteen days 
having elapsed, he was suddenly seized with excruciating pain in the 
epigastrium. It was so severe as to produce an almost convulsive 
state. He now had the usual symptoms of perforation and of peri- 
tonitis, with this exception, that the disease, after its first violence was 
spent, ran a course of eight days before death took place. 

We found the peritoneum filled with fluid, intermixed with large 
masses of gelatinous exudation, which in some places showed a com- 
mencing organization. This exudation was laminated, and its interior 
was traversed by bloodvessels of a deep blue colour. An abscess, 
the size of an orange, communicating with the peritoneal sac by an 
opening capable of admitting a quill, was found in the left lobe of the 
liver. In the right lobe was a cavity lined with a dense membrane, 
and communicating with the duodenum by an opening which admit- 
ted the finger with ease. This accounted for the consequent diarrhoea 
on the subsidence of the first tumour. 

In another case, in which a vast hepatic abscess existed, the opera- 
tion of puncture was immediately followed by dreadful pain in the 
lower part of the belly, and a sensation as if matter was escaping into 
the peritoneum. In a few hours the patient, a woman, showed every 
symptom of acute peritonitis. There were vomiting and screaming, 
the pulse 140, small and wiry ; and the knees drawn up. These symp- 
toms all subsided in a few days under the opium treatment, but she 
sank exhausted in nearly a month from the operation. Universal 
adhesion was found, and the abscess contained nearly four pints of 
purulent matter. 

The influence of an eruption of purulent matter in exciting serous 
inflammation, so far as we have observed it, differs very much from 
the effects of hemorrhage into a serous sac. I have seen a case in 
which, from a rent at the origin of the aorta, a gush of blood into the 
pericardium took place on three separate occasions. • After death no 
evidences of pericarditis were discernible. In a second instance, where 
an aneurism of the abdominal aorta opened into the pleura on three 
occasions, with a considerable interval between the first and second 
and between the second and third hemorrhages, uo trace of pleuritis 
could be discovered. 

This character of the blood is in direct contrast to the irritative 



PUS AND WHITfi BLOOD CELLS. 157 

effect of a purulent fluid on a serous membrane, and goes far to show 
that there must be some essential physiological difference between 
pus and the white corpuscles of the blood. Here, as in many other 
points, physiological conclusions are to be tested by the facts of path- 
ology, and no matter how similar the white blood corpuscle and the 
pus cell may appear under the microscope, we must believe that the 
vital characters of the two are different. 

Since perforation of the peritoneum occurs more frequently than 
perforation of the pleura, it is interesting to consider whether adhesive 
inflammation is a less frequent occurrence in the former than in the 
latter lesion — at least when we speah of cases where the irritation is 
prolonged from the underlying tissues to the serous surface. That this 
seems to be the case in chronic disease there can be little doubt. In 
the ordinary tuberculous disease of the lung, partial adhesions of the 
pleura are almost constant, and consequently empyema and pneumo- 
thorax are very exceptional. "We know little of perforation in acute 
suppurative disease of the lung, and it is certain that in chronic ulcer- 
ations of the intestine, as in phthisical diarrhoea, it is very rare. 
Adhesion may be absent in hepatic abscess — as is seen in India, where 
the abscess may come forward so as to cause discoloration of the 
integument and yet the peritoneum be not adherent over it. This 
comparative insusceptibility of the peritoneum to the adhesive process 
is mentioned by Mr. Annesley. 

That adhesion of the serous membrane in cases of fever with ulcer- 
ated intestine is rare seems certain when we consider the frequency 
of the complication and the number of recoveries in cases where per- 
foration has never occurred. Yet this accident, like every other 
complication in fever, varies in frequency with the epidemic con- 
stitution. 

Still, were you to hold that adhesion and local inflammation of the 
peritoneum never attended cases of underlying suppuration, you 
would be wrong. At the time of the prevalence of hepatic abscess 
in this hospital the disease was often observed as a primary and idio- 
pathic affection, and we had a case in which the signs of adhesive 
inflammation assisted in the diagnosis. 

The patient, a young and strong man, after exposure to cold and 
damp from sleeping on the grass, was next day attacked with intolera- 
ble pain in the loins. He had fever of an inflammatory type. After 
some days the pain in the back ceased, and a tumour with excentric 
and strong pulsation made its appearance in the right hypochondrium. 
The pulse became more rapid, and copious sweatings set in. 

The case was considered to be one of aneurism of the hepatic or 



158 



LECTURES ON FEVER. 



of the abdominal aorta. We came, however, to a different conclusion, 
and looked on it as one of acute hepatic abscess, for the following 
reasons: — 

1st. The history of the case and the time of life of the patient. 

2d. The existence of fever, at first of an inflammatory and then of 
a hectic type. Such a condition, so far as we are aware, is 
unknown in aneurism. 

3d. The pulsation was indeed excentric, and so far like that of 
aneurism. Yet we knew that a pulsation communicated to a 
sac filled with fluid and lying upon an artery acquires this char- 
acter. This fact, therefore, did not exclude the possibility of 
hepatic abscess. 

4th. That when the hand was laid on the tumour a deep inspiration 
enabled us to feel well-marked friction. This was very important, 
as aneurism of the abdominal aorta has little, if any, iufluence 
in causing adhesion of the peritoneum, though aneurism of the 
thoracic may be attended with local pleuritis and adhesion. 

In a few days the contents of a large abscess were discharged per 
anum, and the patient recovered. 

We have seen that the ordinary chronic ulceration of the intestine 
in phthisis rarely spreads to the serous membrane. The comparative 
insusceptibility of the peritoneum to adhesive inflammation in acute 
secondary disease of the intestine increases the obscurity of the diag- 
nosis of this lesion in fever. 

Dr. Beatty 1 details cases of inflammation in ovarian and splenic 
tumours, in which the frottement of peritonitis was plainly felt. He 
also quotes Dr. Bright, and then remarks: "It would appear that 
this method of diagnosis of disease of a serous membrane is applica- 
ble only in those situations where one at least of the opposed surfaces 
is adherent to a solid existing body. I am not aware that such phe- 
nomena as have been mentioned can be perceived in inflammation of 
the peritoneum under ordinary circumstances, where the soft, pliable 
walls of the abdomen are in contact with the mass of the intestines." 

1 Contributions to Medicine and Midwifery, p. 298. 



SEROUS MEMBRANES IN FEVER. 159 



LECTURE XXII. 

Secondary Nervous or Cerebro-spinal Complications op Fever — when they predomi- 
nate, prognosis is unfavourable — Of all secondary typhous affections they are' least 
connected with organic change — Probable reason : mucous membranes and skin 
undergo anatomical change more readily than serous membranes — Cerebral inflam- 
mation rarely observed in fever — Purpuric fever of 1867 an exception — Absence 
of organic change in typhous cerebral derangement does not lessen its importance 
as regards prognosis and treatment — Inadmissibility of routine treatment either 
antiphlogistic or by stimulation, in fever — Results obtained by Louis as to relation 
between head symptoms and pathological change in fever — Actual cerebritis, 
when it does occur in fever, is a tertiary phenomenon — Dr. Hudson's cases — Study 
of analogies is of importance in essential diseases ; thus relief of headache in 
early stage of some cases of smallpox by leeching is analogous to good results of 
moderate depletion in early stages of some cases of fever — Further examples of 
the effect of lessening vascular supply in controlling development of smallpox 
eruption — Analogy in case of secondary affections of fever — Nervous symptoms 
arise from three conditions : (1) influence of fever-poison, (2) ursemia, (3) specific 
secondary inflammation, probably erysipelatous in character. 

We are to-day to study the nervous or cerebro-spinal symptoms of 
fever. I believe it may be held, that, of the various symptoms indica- 
tive of suffering of organs in fever, these are the most remarkable; 
and, when developed to a certain point, the grounds of a worse prog- 
nosis than any others. And yet, so far as investigation has gone, 
they are less often connected with organic change than those belong- 
ing to the digestive, respiratory, or circulatory systems. 

Is there any reason for this ? Not that the question should mate- 
rially influence our practice. Yet, looking at the results of dissection 
in fever, it may be held that the surfaces of relation — the mucous 
membranes and skin — undergo anatomical change far more frequently 
than the serous membranes. Of the three great cavities of the body 
the cerebro-spinal is the least liable to secondary anatomical change; 
an interesting fact when we reflect on the number of violent and extra- 
ordinary nervous affections — epilepsy, chorea, tetanus, hydrophobia, 
mania, and others — on all of which anatomy sheds but a negative 
light. 

The first thing to be laid down is that, as regards fever in this 
country, or rather as it has hitherto occurred in this country, inflam- 
mation, either of the substance of the brain or of its serous covering, 
is rarely observed. The researches of Louis show how little cerebral 
symptoms in fever are to be relied on as indicative of the presence of 



160 LECTURES ON FEVER. 

inflammation. Dr. Murchison 1 says that he has repeatedly known 
the most severe cerebral symptoms during life without abnormal 
vascularity of the membranes after death, and, further, that he has 
met with only two instances where the appearances would justify the 
opinion that inflammation had occurred in typhus. Tn another place, 
in speaking of the diagnosis between cerebritis and the delirium of 
fever, he adduces the existence of the eruption in the latter disease. 

But you will be ready to admit that the cerebral symptoms in fever, 
in regard to their connection with organic change, are under the same 
law as those of the digestive and pulmonary systems, and that they 
share with these the characters of inconstancy in occurrence, in amount, 
and in their connection with organic change. This inconstancy you 
will see influenced by the epidemic character and in isolated cases ; and 
whether the symptoms are or are not associated with organic change, 
they also show a subjection to the law of periodicity. 

I can add my testimony to that of Dr. Murchison as to the rarity of 
cerebritis in fever; indeed I never saw an example of it in the dead 
body before or after 1867, when the epidemic (if it may be so called) 
of the purpuric fever with cerebro-spinal symptoms furnished many 
cases to our wards. This was an example, as it were, of an epidemic 
within an epidemic — like the occurrence of the yellow fever of which 
I have already spoken. Arachnitis as a secondary affection of the 
brain and spinal cord was then common enough, so that the name of 
cerebro-spinal fever could be justified, if the existence of organic 
change of the nervous centres is to be made the ground of nosological 
distinction. 

It is, then, to be admitted that, so far as the actual state of our 
knowledge of the affections of the three great cavities in fever is a 
guide, those of the brain are the least connected with anatomical 
change. It is possible that at some future day chemical or microscopi- 
cal research will succeed in discerning anatomical change corre- 
sponding with the manifold nervous conditions of fever. As yet, 
however, this has not been done. On the other hand, if you were to 
conclude that nervous symptoms are of less importance because we 
cannot connect them with ascertained organic states, you would fall 
into great error — as regards treatment and prognosis they are of the 
greatest importance, for they reveal a state of deranged function 
which may be, and often is, fatal, although there is neither inflamma- 
tion, nor deposit, nor any known constant or distinctive anatomical 
change. 

The assumption of inflammation of the brain in the presence of 

1 Continued Fevers of Great Britain. Second edition, p. 2(J0. 



IMPORTANCE OF CEREBRAL SYMPTOMS. 161 

violent nervous symptoms in fever constitutes one of the greatest 
dangers to which young physicians are exposed, when they come to 
deal with the most formidable complication of the disease ; aye, and 
old physicians, too, whose clinical education has been imperfect. I 
have known of the application of leeches to the head in an advanced 
case of cerebral fever with delirium ferox to be followed by sudden 
sinking and death. I have told you how an eminent apothecary in 
this city, the late excellent Mr. Packenham, while he was an appren- 
tice in one of the first establishments in Dublin, would be commonly 
sent to remove the leeches from the temples on the death of the 
patient. The doctrines of the anatomical school — a school which 
denied essentialities, and with which all diseases were symptomatic 
of a local irritation — naturally led to a routine practice. The more 
violent the local symptoms, the more intense the inflammation was 
held to be, and in consequence the more vigorously and continuously 
the antiphlogistic treatment was pursued. I once saw in Paris a 
caricature in which a patient was stretched in bed in articulo mortis 
surrounded by three physicians. His countenance was hippocratic, 
and it was plain that the hour of deliverance from the disease by 
death was at hand. The principal figure among the attendant physi- 
cians, intended for Broussais, exclaims, "Encore des sangsues. " 

But the doctrines of Broussais, of Bouillaud, of Clutterbuck, and 
of Armstrong are now matters of history, thanks to the researches 
of Louis and of Andral into the pathological anatomy of fever — 
" that disease" (to use the words of Louis) "called gastro-enteritis" 
— and thanks to the influence of the writings of the fathers of British 
medicine — of Sydenham, Hay garth, Fothergill, and Heberden — and 
on the Continent of John Peter Frank. Truth, though for a time 
obscured, conquers in the end. The teaching of these great men has 
triumphed over the innovations of the so-called physiological medicine. 
A more accurate observation, a truer interpretation of phenomena, 
a greater respect for the recorded experience of such men as those 
I have mentioned, have resumed their sway over the medical mind, 
and every day the routine application of the antiphlogistic or the 
stimulant treatment is less and less seen. It is right, however, to 
observe that the disuse of the routine antiphlogistic treatment is not 
altogether to be attributed to more modern research. 

When studying fever, you will find that what applies to one 
symptom applies more or less to all. Thus, when we study the 
relation between organic change and delirium, we may safely adopl 
the same conclusion with regard to all the nervous symptoms, such as 
coma, convulsions, and so on. Louis, in his work Recherches sur la 
11 



1'02J 



LECTURES ON FEVER. 



G astro- Entente (page 155), compares the results of twelve dissections 
in cases of fever where delirium was absent, or only passing and 
slight, with those of twelve other dissections where this symptom was 
most violent and persistent. In a former lecture I have given the 
results of his observations, but I may be pardoned for reproducing 
them here in a tabular form. 



Delirium absent. 

Cases 
Redness of cortical substance of the 

brain 4 

Inflammation of optic thalamus . 1 
Slight softening of brain . . .1 

Brain anatomically healthy . .< 6 



12 



Delirium present and violent. 



Cases 



Slight reddening of cortical substance 
Slight softening of brain . 
Livid venous injection of mem- 
branes of the brain 
Brain perfectly healthy 



12 



Now, looking at these tables, it is impossible to avoid seeing that 
there is no constant relation between the anatomical changes of the 
brain and the symptoms. In the general progress of fever, as I have 
told you, the nervous symptoms may be considered of the greatest 
importance, and in the present state of our knowledge we must refer 
them to the effects of the poison of fever. Whether that poison acts 
directly and in the first instance on the nervous centres, or indirectly 
on them through the medium of the blood, is a question which may 
still be asked. They are, at all events, in their early stages to be 
looked on more as functional than as organic symptoms. But, in the 
nervous as in the pulmonary and abdominal symptoms, we find incon- 
stancy and irregularity in the visible alteration of the organ. It 
would in any case, however, be an error to assert that there are no 
cases of secondary nervous engagement, in which local antiphlogistic 
treatment is to be used. We might as well say that there are no cases 
in which cupping of the chest, or the application of leeches to the 
ileo-ca3cal region, was useful. 

That actual cerebritis does occasionally occur in fever is certain. 
It is very probable that it is a tertiary phenomenon in the case — the 
steps being, first, fever; then, deposit ; and, lastly, reactive inflamma- 
tion. I do not apply the observations I now make to the cerebro- 
spinal or purpuric fever, although when cerebritis does occur in fever 
it seems to depend on an epidemic tendency. You. will see in Dr. 
Hudson's work 1 an account of three cases in which true inflammation 
of the brain and its membranes was proved on post-mortem examination 
to have occurred in the course of fever. In one case head symptoms 



Lectures on the Study of Fever. Second edition, p. 252. 



CEREBRITIS IN FEVER. 163 

of a very severe nature became developed about the eleventh day 
of maculated typhus. Four days later the patient died. On exam- 
ination the dura mater was found sensibly thickened, the sub- 
arachnoid fluid considerably increased in quantity, and the vessels of 
the brain and its membranes much congested. The cerebellum and 
medulla oblongata were to some extent softened. The second patient 
from the time of his admission lay in a state of increasing stupor, 
with ptosis of one eye, strabismus, retention of urine, and finally 
dysphagia. Here there was intense venous congestion of the cere- 
bellum and upper part of the cord and a circumscribed collection of 
yellowish- green pus lay included beween the arachnoid and the 
under surface of the cerebellum. The arachnoid itself bore traces of 
inflammation. In a third case similar appearances were observed. 

Dr. Hudson also quotes some cases of a like kind which were 
communicated to the Pathological Society by Sir Dominic Corrigan. 
" While," says Dr. Hudson, "you must endeavour, on the one hand, to 
avoid the mistake of ascribing the nervous derangements caused by 
the toxic action of the fever poison to cerebral inflammation, you 
must, on the other, avoid the opposite error of ignoring the existence of 
true inflammation, when this is indicated by the groups of symptoms 
enumerated above, whether it occurs in the form of acute congestion 
of the brain, as in some epidemics of typhus, of epidemic cerebro- 
spinal arachnitis, of arachnitis, or as the effect of previous injury, or of , 
reactive irritation and inflammation, set up in the advanced period of 
typhoid fever." 

In the investigation of disease, especially in that of fevers, the 
study of analogies is of great importance; and looking at the lia- 
bility of essential affections to induce secondary local conditions, we 
may expect the brain also to be subject to this liability, the result 
being a neurotic or functional condition followed or not by anatomi- 
cal change. Why it is that the latter result seems so rare we have 
as yet no means of determining. It may indeed, unless reactive irrita- 
tion occurs, be overlooked in examinations after death. It is not 
easy to distinguish the toxic influence of fever from the signs of 
primary or of reactive inflammation. Yet, although it be admitted 
that the nervous symptoms are generally functional, the relief afford- 
ed in certain cases by a few leeches, the cold affusion, and the use of 
ice to the head, indicates a condition which — if not actual meningitis — 
is related to or may possibly be a precursor of it. And it may be 
asked whether the secondary effect of fever may be locally modified 
or arrested by a lessening of the blood supply. I have published a 



164 LECTUKES ON FEVER. 

case of variola which illustrates the arrest of local development of the 
pustules. 

A young and healthy woman was admitted with severe fever of a 
sthenic type. She was about three days ill, and complained of intense 
headache, far more violent than that met with in the early periods of 
ordinary fever. The face was flushed and turgid. Looking on the 
case as exceptional, we applied leeches freely to the temples. This 
was followed by relief of pain ; the redness of the face disappeared, 
as did the fulness. Next day smallpox vesicles appeared, on the 
breast and arms', and there was soon a plentiful crop of pustules 
running into confluence over the entire body, with the exception of the 
face, where but one or two small and aborted pustules formed. 

We have found, too, in variola, that where the appearance of the 
vesicles on the face was attended with heat and vascularity, the appli- 
cation of leeches rendered the after-pustulation so much more benign 
that this mode, together with the use of light poultices, has been 
found most efficacious in preventing the subsequent pitting of the 
face, and we have therefore commonly employed it. 

In a remarkable case of severe confluent smallpox the patient had 
been an inmate of the surgical ward for a chronic affection of the 
knee, for which the joint was strapped with mercurial plaster. Of 
this I was not aware till the stage of decrustation arrived, when the 
strips of plaster which had tightly bound the knee fell off, and this 
singular appearance was seen. The face and body generally presented 
black, thick, and fetid crusts, but the knee for a space of seven 
inches was of a pearly whiteness, without a trace of pustulation, and 
contrasting strangely with the condition of the skin above and below 
the joint. Here the pressure by the straps had lessened the vascular 
supply. 

Now, regarding the eruption of smallpox as a secondary and local 
manifestation of that disease, as there is no doubt it is, we see it, in 
the instances just quoted, controlled by local depletion or lessening of 
the blood supply. The similar relation between the nervous symp- 
toms in fever and the local treatment I have referred to is at once 
interesting and suggestive. 

We may hold in practice that the nervous symptoms in fever arise 
from the following conditions : — 

a. The influence of the poison of fever. 

b. The occurrence of the urosmic condition. 

c. The occurrence of an inflammation, probably of an erysipelatous 
and also of a specific nature, analogous to that in the other 
secondary affections of fever. 



EPIDEMICS WITHIN EPIDEMICS. 165 

Of these the first two may be considered as functional or neurotic, 
and, remembering the quality of inconstancy as to the period of 
appearance of the secondary symptoms in fever, we find that any, or 
any combination, of these may occur at various stages of the disease. 



LECTURE XXIII. 

Nervous Complications of Fever, continued — Cerebrospinal fever — Phenomena of fever 
inconstant and variable, except, perhaps, the phenomenon of increased tempera- 
ture — Type of fever also varies in different epidemics — -Two examples : (1) yellow 
fever of 1826-27, (2) malignant purpuric, or cerebrospinal fever of 1867 — Dr. E. W. 
Collins' report on latter — There exists a " constitutional element" in the disease, so 
that the cerebro-spinal arachnitis can hardly be held to be a primary, idiopathic 
affection — Evidences of essentiality from presence of other phenomena in connec- 
tion with the skin, etc. — Reports to the Medical Society of the King and Queen's 
College of Physicians in Ireland on the epidemic of 1867 — Inconstancy and variabil- 
ity of the symptoms in the outbreak — Dr. H. Kennedy's views — Symptoms of the 
disease — Petechias — Early setting in of putrefraction — Retraction of head: some- 
times persistent after disappearance of other local and general symptoms, and 
sometimes persistent after death — Recapitulation : Points to be considered in 
connection with epidemic of 1867 : (1) yellow fever of 1826-27, (2) cerebro-spinal 
arachnitis of 1846 (Dr. Mayne), (3) coincidence of cases of malignant measles in 
1867, and (4) hsemorrhagic and purpuric smallpox iu epidemic of 1S71-72. 

I have on many occasions sought to impress on you that fever is a 
condition which, though possessing a generic character, exhibits 
infinite varieties in most of its aspects, whether it be looked on in 
its sporadic cases or as occurring in great epidemics. There is no 
point of view in which any of its phenomena can be regarded as con- 
stant, except perhaps that of increased temperature. The epidemic 
of one period is found to differ from that of another, whether we look 
at its commencement or decline, its intensity or mortality, or the in- 
fluence of remedies. And this quality of variability applies to the spo- 
radic cases also, whether considered individually or collectively. The 
disease varies in its contagiousness in different epidemics as the con- 
dition of receptivity in healthy bodies varies, and this state of recep- 
tivity is different according to the period. It is changeable as to its 
degree of intensity, the number and nature of its complications, and 
the vital phenomena of the secondary affections, their progress and 
their influence on the disease as to its danger and its periodic laws, 
and all this whether local symptoms are merely functional or reveal 
organic change. 



166 LECTURES ON FEVER. 

This will prepare you for the occurrence at irregular intervals of 
time of groups of unusual cases having on the one hand a generic 
resemblance, yet varying as to their local manifestations, and this is 
what we mean by the term of epidemics within epidemics. 

Now, the variation from the type of the general and coexisting 
epidemic may be seen in both the essential and the local characters. 
We have had two most remarkable examples of this in Dublin. 
One of these was the yellow fever of which I have already spoken, 
characterized by violent and sudden abdominal spasms, followed 
rapidly by jaundice and mortification of the nose and toes; and the 
other the disease which has so many names — the cerebro-spinal fever, 
the malignant purpuric fever, epidemic cerebro-spinal meningitis, 
febris nigra, etc. 

Now, I recommend all of you to carefully study the report on this 
disease by Dr. Collins in the Dublin Quarterly Journal, 1 which may 
be taken as a model of what a scientific and faithful medical report 
should be. This variety of fever appears first to have attracted atten- 
tion in America early in this century. Dr. Collins shows that the 
first account of the cerebro-spinal fever is that of an epidemic which 
prevailed in Geneva in 1805. The disease showed itself in various 
places in Europe and in America. Then it continued in America, and 
in 1837 it became a widespread epidemic, occurring in Germany, Eng- 
land, Ireland, and Denmark, and appearing at many ports in Spain, 
North Africa, and Italy. In the British and Foreign Medico- 
Ghirurgical Review, 2 you will find an excellent resume of the reports 
of the American, German, and British physicians. This article is 
written in that philosophical spirit which has so long distinguished 
the periodical just mentioned. The name in use in America for this 
disease was the spotted fever. Discussions arose about the nature of 
the disease, some holding it to be an essential fever related to typhus, 
if not typhus itself; others, a true cerebro-spinal meningitis. But it 
is plain that the relation between the nervous symptoms — and also 
the state of the brain and spinal cord — and the general symptoms 
was not fully understood. The great fact of the secondary lesions in 
fever varying in amount, prominence, seat, result, time of appearance, 
was not yet appreciated, while the doctrine of the anatomical school, 
that fever was symptomatic of a local irritation, made men look upon 
the structural change as the cause of all the symptoms, while it was 
truly the effect, though when it occurred it produced special pheno- 
mena of a striking kind. It is true that Dr. Gordon found the marks 
of cerebro-spinal inflammation within five hours from the occurrence 

1 Vol. xlvi. August, lS6S,p. 170. 2 Vol. xlii. p. 389, and vol. xliii. p. 1 32 



NATUKE OF THE AFFECTION. 167 

of the first symptoms of the constitutional malady, though the special 
signs of cerebro-spinal irritation were wanting, and Levy has recorded 
another case of singular rapidity of morbid action. Arguing from 
these cases and from another in which extensive exudation in the 
meninges was found after thirty hours of illness, Dr. Collins, while 
admitting a constitutional element in the disease, holds that, since the 
products of inflammation became developed in so short a period of 
time, the inflammation itself from which they sprang cannot be con- 
sidered other than primary and as forming along with the constitutional 
element the pathological essence of the disease. 

Now, the admission of the constitutional element is to give up the 
doctrine of primary cerebro-spinal meningitis ; for what is this but 
fever, with secondary nervous symptoms and organic states ? 

"Congestions," writes Dr. Collins; 1 "plastic, purulent, sero-purulent, 
or serous exudations; sometimes even alterations of the nervous sub- 
stance itself, of ever-varying extent, singly or together, bear their 
testimony to the nature of these inflammatory processes. But these 
inflammatory changes, constant though they be, are not the only, nor 
are they always the most important, features of the disease. Behind 
them all, as in other affections, modifying and at times predominating, 
lies another, a constitutional element, which gives to the disease so 
many of its varied and. most appalling characters. This constitutional 
element, the importance of which cannot be over-estimated, is re- 
markably exemplified in those malignant and rapidly fatal cases of 
meningite foudroyante, so called, which occurred within the past two 
years throughout this island. The lesions here found, in many 
instances, have been only varying degrees of congestion of the pia 
mater, and similar experience is not wanting from the records of other 
epidemics, so that some French writers have even given to this form 
of the malady the title of forme canrjestionelk." 

Now, this term " meningite foudroyante" is improper. It conveys a 
false idea of the whole disease, leading to the belief that all its symp- 
toms, the rapidity of its progress, and its fatal results are only measures 
of the intensity of a primary local inflammation. But that the 
"constitutional state" of Dr. Collins is of the nature of fever generat- 
ing local disease — as scarlatina commonly generates sore throat; 
measles, bronchial irritation ; and typhus and typhoid, pulmonary 
and abdominal diseases — is obvious when the relation between the 
local and constitutional state is considered. Its amount is variable, 
and does not necessarily correspond to the violence of the symptoms. 
In some of the most rapid cuses there is nothing observable but 

I Loc. oit. p. 201. 



168 LECTURES ON FEVER. 

congestion of the pia mater, and the degree of meningeal inflammation 
has been found, as in the secondary affections of fever, to vary accord- 
ing to locality and time — in other words, according to the local 
epidemic. 

To show that the cerebro-spinal arachnitis can hardly be considered 
a primary idiopathic affection in this disease, the coexistence of other 
local affections is to be noticed. Thus, great swelling of the eyelids 
and conjunctivitis, with deep-seated injury of the eye; deafness, often 
without, but occasionally with, purulent discharge; aphthae; swelling 
of the parotid, submaxillary, and cervical glands, with or without 
consequent suppuration, have been described. Epistaxis, meteorism, 
diarrhoea, enlargement of the spleen, broncho-pneumonia, and occa- 
sionally pericarditis, have been noticed by various observers in differ- 
ent localities and at different periods. 

Yet there are other evidences of its analogies to essential disease — 
the occurrence of herpes; of a dusky discoloration of the skin, as in 
typhus; of extraordinary petechial spots running occasionally into 
vast ecchymoses, so as to evoke the designation of black death, and 
the occurrence of a condition of the joints similar to that described 
long since by the late Dr. MacDovvel. This at first simulates rheu- 
matic arthritis, but soon shows the signs of purulent deposit. All this 
confirms the view which was long ago taken in this hospital, and more 
lately set forth by Stille, that this disease is a combination of an essen 
tial specific condition, analogous to fever, with an important local and 
consequent lesion of the nervous centres. The variations of pheno- 
mena, both essential and local, though these present a generic resem- 
blance, the differences of results of post-mortem examination — all are 
plainly referable to the laws of essential epidemic disease occurring 
at various times and in various parts of the world. 

That the remarkable local affection, which gave a name to the epi- 
demic we are considering, agrees in its general characters with the 
secondary lesions of other varieties of fever, is evident from the truly 
able and practical paper by Dr. Gordon in the forty-third volume of the 
Dublin Quarterly Journal; and also from the records of two succes- 
sive meetings of the Medical Society of the King and Queen's College 
of Physicians in 1867. At these meetings not less than twenty-seven 
observers of the disease in Ireland during the epidemic of 1866 and 
1867 recorded their experience of it. I do not know of any greater 
illustration of the healthy state of medical opinion in Ireland than 
that afforded on this remarkable occasion. Most of those who gave 
reports of cases and the results of their experience were physicians 



ESSENTIALITY OF THE DISEASE. 169 

to some of the Dublin hospitals, while reports were also read by some 
military surgeons then quartered in Ireland. 

The occurrence of the nervous symptoms and the condition of the 
nervous centres had received great attention from most of the ob- 
servers. I may state that these meetings were more for the purpose 
of recording individual experience than for discussion, of which there 
was very little ; and when among the reporters were men of such mark 
as Drs. Hudson, Gordon, Lyons, Hayden, Law, Banks, Henry Ken- 
nedy, and Moore, you can understand the great importance of the oc- 
casion. 

Now, I claim no originality for the views I have submitted as to 
the primary or the secondary nature of the cerebro-spinal disease. 
Gentlemen, there is nothing more deplorable than the contests among 
our brethren respecting priorit}' in observation and doctrine. I have 
spoken of this in my lecture on medical ethics, and have shown you 
that when several observers are working for the same object and at 
the same time — similar views will occur to many of them simulta- 
neously. This applies to all investigations. It is of the first import- 
ance that the truth should be made known, but by whom it was first 
suggested matters little indeed. 

If you study the cases brought forward at the College of Physicians, 
you will find that the character of inconstancy attended the symptoms 
of meningitis, and also the structural alteration. In one of the very 
worst cases which I saw with Dr. Lyons death took place in little 
more than twenty-four hours. The patient was a fine young man, an 
officer in a cavalry regiment. There was no retraction of the head. 
Dr. Lyons recorded two other fatal cases in which the peculiar cere- 
bro-spinal symptoms were absent. In the 52d Regiment five cases 
were reported by Mr. Haverty. The third case proved fatal in sixteen 
hours after admission. There was no pain in the head, no retraction ; 
nothing unusual was found in the brain, but at its base an increased 
quantity of serum, which was of a dark colour. In a case which oc- 
curred in this hospital with recovery, there was no retraction of the 
head. The patient had slight converging strabismus and dilated pu- 
pils. In a case by Dr. MacSwiney no lesion of the brain or spinal 
cord was discovered, and Dr. Kennedy stated that many similar in- 
stances had been met with by others, in which, as in Dr. MacSwiney's 
case, there were no symptoms of arachnitis and no lesion of the nerv- 
ous centres found after death. Dr. Banks, also, said that in many 
fatal cases in this epidemic no signs of cerebro-spinal meningitis were 
discovered after death. 

Dr. Kennedy remarks on this subject as follows: "Taking, then, 



170 LECTURES ON FEVER. 

all the facts at present known, and more particularly the one that our 
typhus fever has, within these two years (he spoke in 1867), been fre- 
quently complicated by spinal arachnitis, into consideration, it ap- 
pears to me that no other conclusion can be arrived at than that the 
late terrible disease which has visited us is a specific fever, and that . 
the spinal arachnitis is but a complication, which may or may not be 
present." 

It is needless to insist on the importance of all this, as showing 
(what might have been predicated) that the disease in its essence was 
not primary inflammation of the cerebrospinal meninges. We have 
seen fatal cases in which it might have been said that there were 
never any symptoms of inflammation of the nervous centres, while, 
on the other hand, every shade or degree of such symptoms have 
been met with. We had one case here in which convulsions contin- 
ued through the whole illness; and the state of the brain and spinal 
marrow varied from the condition of freedom from disease in some in- 
stances to one in which the base of the brain and spinal cord were 
bathed in pus. 

This variability in the amount of the local disease is thus strictly 
analogous to what we observe in the secondary intestinal lesions of 
typhoid. 

It appears, then, that a form of cerebro-spinal disease with menin- 
geal inflammation has been observed to commonly but not universally 
attend this singular malady in America and in Europe. It has been 
revealed by pain in the head, rachialgia, opisthotonos, trismus, and 
occasionally convulsions. Yet it throws no light on the constitutional 
state to which it appears secondary. It is variable in its occurrence, 
inconstant in its amount, and incompetent to account for the general 
malady. In short, it has all the characteristics of a secondary rather 
than of a primary local malady. It is often associated with other 
forms of local visceral disease. 

There is nothing more appalling than the appearance of many pa- 
tients in this affection — the dark petechial spots soon become confluent, 
and vast black ecchymoses form. In a patient who m I saw with Dr. 
Croly a few petechial spots appeared on the neck on the first day of 
illness. Next morning these had become black, and increased in size 
so rapidly that they seemed to grow under the eye of the observer. 
At eleven o'clock the spots were extremely large, and in the course 
of two hours the entire right arm and half of the right side of the chest 
had become continuously black, with large patches over the rest of the 
body. Soon after this a fit of convulsions came on, and the patient 



RETRACTION OF HEAD. 171 

died at half-past two. The duration of the illness was about thirty 
hours. 

Another case is given by Dr. Croly in which the disease set in with 
vomiting, followed by severe diarrhoea. On the second day blue spots, 
soon becoming black, appeared on the sufferer's legs, and shortly be- 
fore death on her arms and face. She died in convulsions with forci- 
ble retraction of the head. The duration of illness was twenty-eight 
hours. 

In some instances, where this terrible disease had run a rapid course, 
putrefaction appeared to have set in at a very early period after, or 
even before, death. I was called to see a patient in whom the symp- 
toms had first developed themselves but twenty-eight hours before. 
He had just died as I entered the room, and I shall not soon forget 
the overpowering stench of putrescence which rose from the still warm 
body. The ordinary medical attendant assured me that the stench 
had been observed some time previously to death. 

Two interesting facts in connection with a remarkable symptom of 
this disease — I allude to the retraction of the head — deserve to be 
mentioned here. The first is the occasional long continuance of the 
rigidity after all constitutional and local symptoms have disappeared. 
I saw a boy in whom the retraction was so great that he could lie only 
on his belly, and in this position he remained for several weeks, dur- 
ing which time his general health was excellent; he took much nourish- 
ment and gained flesh. In another case the retraction did not appear 
until just at the subsidence of the constitutional condition. It in- 
creased with the patient's convalescence until at last, when all febrile 
condition had ceased, it became so extreme that his head was bent 
backwards almost at a right angle with his body. This extraordinary 
retraction subsided with remarkable rapidity, and had quite vanished 
within 48 hours. 

The second point is the occasional persistence of the rigidity after 
death. It has been supposed that the muscles which have been thus 
contracted during life are not liable to the rigor mortis, but in a re- 
markable case published by Dr. Gordon in his Report on Gases of 
Fever icith Cerebro -sinned Meningitis 1 all the constitutional and local 
symptoms of the disease were present, opisthotonos being extreme, and 
continuing after death. On the fifth day of the disease the patient, a 
girl aged 15, lay on her abdomen, and refused to allow herself to be 
moved on the back, or on either side. Her spine presented a most 
wonderful and uniform curve, concave backwards; her head was also 
curved backwards on the spine of the neck. Dr. Gordon had not seen 

1 Dublin Quarterly Journal, vol. xl. p. 412. 



172 LECTURES ON FEVER. 

so much opisthotonos in the worst cases of tetanus. She had no pain 
or tenderness on pressure on any point of the spine. She died on the 
ninth day of her illness, and after death the body presented a very 
frightful appearance. It was still prominently arched forward. It 
was of a dusky blue colour, with a copious eruption of black spots, of 
various sizes, from that of a small pea to a crownpiece; some small and 
circular, others large and irregular in form. 

Now, in reviewing the results of our experience in this hospital, to- 
gether with the published reports of the disease in Ireland, Germany, 
and America, we must, I think, agree with all the best observers that 
to look upon the affection as simple and idiopathic cerebro-spinal 
meningitis would be erroneous. It is quite true that the frequency of 
actual disease of the cerebro-spinal centres is a most striking peculiar- 
ity, yet that this condition should be placed in the category of local 
affections secondary to an essential malady is more than probable. 
Like this class of diseases generally, even where it shows itself early 
in the case, the cerebro-spinal complication does not seem to take the 
initiative. We have had examples here in which the symptoms of the 
local malady failed to appear until after the seventh or even the ninth 
day, although the other characters of the disease were strongly marked. 
I have already spoken to you of the character of inconstancy in 
amount which it has in common with other secondary lesions, and not 
only in amount but in intensity. Like them, too, it may occasionally 
be absent. Nor can we attribute the remaining phenomena of the 
disease — the enormous ecchymoses, the rapidly increasing and dark 
petechias, the gangrene of the skin, and the tendency to general putres- 
cence — to the occurrence of a primary cerebro-spinal inflammation. 

In connection with the extraordinary epidemic in Ireland of which 
I have been speaking, the following circumstances are worthy of re- 
membrance : — 

First. The occurrence of the cases of so-called yellow fever, de. 
scribed by Dr. Graves, in the epidemic of 1826 to 1830, in 
which there was blackening and mortification of the feet and 
the nose, with jaundice, black vomit, and splenic enlargement. 
Secondly. The outbreak of cerebro-spinal arachnitis in Dublin and 
its neighbourhood in 1846, an account of which is given by 
Dr. Mayne in the Dublin Quarterly Journal, vol. ii. p. 95. The 
collapse stage in the worst cases he describes as closely resem- 
bling cholera. This stage was ushered in by violent pain in the 
abdomen, rapidly followed by vomiting, and not infrequently 
by purging. The extremities then became cold and bluish, and 
the pulse a mere thread. There was no cutaneous eruption or 
hemorrhage. 



ANALOGIES. 173 

Although Dr. Mayne does not deal with these eases as examples of 
essential disease, but rather looks upon them as primary inflammation, 
yet analogy and the history of the febris nigra make it highly probable 
that the cerebro-spinal inflammation was not a primary affection in the 
strict sense of the word. In the collapse cases noticed by him, after 
the lapse of a few hours, reaction, more or less perfect, ensued ; the sur- 
face became hot, the pulse full and frequent (from 120 to 140) ; the 
stomach often continued irritable, whilst an intolerable thirst torment- 
ed the sufferer. 

Thirdly. The coincidence of cases of malignant measles with the 
recent epidemic of cerebro-spinal fever — a fact noticed by Dr. 
Gordon, and of which I have recorded a remarkable example 
in the Transactions of the Medical Society of the College of Phy- 
sicians. 
And, fourthly. The extraordinary prevalence of purpuric and 
hemorrhagic smallpox in the late terrible epidemic in Dublin. 
I think that when you reflect on what has been now said, and on 
these latter remarkable facts, the doctrine of a cerebro-spinal menin- 
gitis independent of the general causes of essential disease, whatever 
these may be, cannot be entertained. 



LECTURE XXIV. 

Nervous Complications op Fever, continued— Hysteria— Occurrence of hysteria, espe- 
cially at an early stage, of unfavourable import— View that hysteria is always symp- 
tomatic of uterine excitement is quite erroneous — Nymphomania only a local and 
accidental manifestation — Hysteria is observed in males as well as in females in 
fever — Case of erotic symptoms in typhoid fever occurring in a young girl, reported 
by Dr. A. W. Foot — In early stage of fever hysteria generally is the precursor of 
severe nervous symptoms— Its appearance may lead to serious complications later in 
the disease — Illustrative cases— Hysterical symptoms are sometimes connected with 
actual or organic disease, especially in acute affections — Dr. Cheyne's observation: 
Hysteria a ground for a good prognosis in every disease, fever alone excepted — Outbreak of 
hysteria, affecting the abdomen, in female fever ward of Meath Hospital — Anoma- 
lous symptoms in advanced stages of fever often due to hysterical state— Case of 
typhous hysteria in the male followed by cerebritis. 

One of the nervous conditions in fever still remains to be considered. 
I refer to hysteria, the occurrence of which, especially in the early 
periods of fever, should always excite apprehension as to the result. 
I have often told you that you are to reject the common notion that 
hysteria is always symptomatic of uterine irritatiou, and that the oc- 



174 LECTURES ON FEVER. 

currence of hysteria in a woman was owing to ungratified desires. 
I would advise you not to enter practice, whether your patients be in 
the humbler ranks of life or in the more refined walks of society, with 
this gross, degrading, and ignorant idea. 

We cannot doubt that in certain cases of hysteria there is evidence 
of excitement of the genital system, but this result of the general disease 
is only one — it may be — of a series of local excitements. The hys- 
teric condition may affect the brain, and you may have intense pain, 
coma, mania, and convulsions. If the lung be affected, dyspnoea, 
cough, expectoration, even haemoptysis, may be observed. Hysteric 
palpitation and syncope occur when the disease falls on the heart, vo. 
miting when it affects the stomach, paralysis when the bladder is 
engaged, and so on. It is easy to understand that if the disease fastens 
itself upon the uterus and the genital system, symptoms of nympho- 
mania may be produced. 

In fact, in cases of hysteria with excitement of the genital system it 
has merely happened, and accidentally, that upon that system the brunt 
of the disease has fallen, while, if any other organ had been affected, 
there would have been no symptoms of nymphomania; but mania, 
convulsions, palpitation, cough — the tussis ferina — or uncontrollable 
vomiting might have been present, according to circumstances. 

Indeed, the occurrence of hysteric symptoms in fever in the male 
as in the female is almost conclusive that it is a special nervous affec- 
tion, the origin of which is unknown — an affection which may engage 
every great organ in the body, which is not symptomatic of irritation 
of any one of them, and whose seat is in the nerves of animal and 
organic life. 

Let me again impress upon you that the old and still too common 
view of hysteria is to be rejected as one based on ignorance of the 
female constitution and of medicine. You will hear it advocated only 
by men of gross and prurient ideas. It is true, that, when the genital 
system happens to be engaged in the hysteric state, there is a liability 
to nymphomania, and you may hear expressions and witness actions 
in the purest females that may surprise you ; but remember that these 
are but the symptoms of a secondary local manifestation of a general 
malady. Hysteria, as its name implies, was held to be symptomatic 
of irritation of the uterus, just as fever was considered as symptomatic 
of cerebritis or muco enteritis. 

It is true that in fever we have not yet observed any erotic symptoms 
in the male subject, but in the young female they are oceasionally met 
with. A case of this kind recently occurred in these wards under the 
care of Dr. Foot. A young woman was admitted on the eighth day 



CASE OF HYSTERICAL COMPLICATION. 175 

of an enteric fever. Her pulse was 100 and temperature 99.5°. She 
was talking and gesticulating in such an erotic manner that the nurse 
suggested her separation from the other patients. She laughed in- 
cessantly, and exhibited all the symptoms and action of violent excite- 
ment of the genital system. This continued all that day and night. 
Next morning the pulse was 114 and the temperature 101.3°. The 
head, hands, and feet were very cold and livid. The heart's action 
was weak. This patient was a blonde, with very light hair and blue 
eyes. She hid her face from the physician, then jerked it round, took 
a look at the class, and hid it again. She took a double meaning out 
of every question put to her. In reply to ordinary questions as to 
headache, etc., she said, with a knowing laugh, "I know you all well. 
I won't let you; you won't succeed. I know what you're about." In 
words such as these she addressed both the physician and the class in 
general. It was impossible to get an answer from her. Her manner 
and conversation were jocular, immodest, and disrespectfully familiar. 

She was ordered 30 grains of chloral at once, and immediately went 
to sleep. After the effects of the chloral had passed off she was ordered 
30 grains of bromide of potassium every third hour. Next morning 
she was a different person — timid, respectful, gentle — and she did not 
recollect a word of what she had said the day before. This fact was 
further ascertained through the nurse to be true, as shame might have 
led her to feign forgetfulness to the students. On this day, the 10th 
of her illness, several rose spots appeared for the first time on her 
chest. She subsequently went through a well-marked enteric fever, 
on the 28th day of which her temperature permanently fell, having 
ranged during her illness between 101.8° and 97.2°. As there was 
constant and characteristic diarrhoea, and as t,he lungs became the seat 
of congestion at one period, the case afforded an example of secondary 
complication of the three great cavities of the body. 

The patient's manner subsequent to the hysterical attack was most 
decorous. She did not appear to possess a particle of what is called 
the " hysterical temperament." So far from seeking for or seeming to 
like any attention, she was so distant and indifferent to the pupils as 
sometimes to appear impolite. She bore an excellent character prior 
to admission, and her parents intended to have nursed her at home, 
but got alarmed "when she got out of her mind," and brought her to 
the hospital. 

Many a time I have known of a deep wound inflicted on the delicacy 
of the purest girl by the expression of these — T may call them brutal 
— views on the part of the attendant — views which show that he is at 
once ignorant of the physiology and of the pathology of the female 



176 LECTURES ON FEVER. 

constitution, and of the moral nature of that sex, which is the deposi- 
tary of all that is pure and delicate and moral in this life. That man 
is unworthy of confidence or of the name of a ph ysician who thus 
drags his profession into the mire. 

In the early periods of fever hysterical symptoms generally usher 
in a great severity of many of the nervous conditions of the disease, 
while their later occurrence gives rise to singular and often embarrass- 
ing complications even after the fever has run its course. 

This is illustrated by the case in the wards. The girl had recovered 
from fever, when she was agitated at seeing one of her friends brought 
sick into the ward, and soon fell into her present condition. She lies 
in a prostrate and stupid state, though answering questions rationally. 
She complains of pain at the top of her head. The breathing is 
natural, but at times hurried and croupy. Any attempt to examine 
the throat brings on the most violent spasms, attended by hysterical 
singultus. Now, has this patient irritation of the brain or of the 
larynx ? It is most probable she has neither, but you must remember 
that she has recently had a continued fever, and so we must act as if 
she were threatened with cerebral or laryngeal irritation, although of 
course in a very tentative way. 

A case which left a deep impression on my mind occurred with us 
some years ago. It shows how actual organic change may be masked 
by the hysterical complication. A young woman was an inmate of 
this hospital for many months, presenting a succession of the most 
violeut and various local symptoms of hysteria. In fact, almost every 
organ of her body was in turn attacked. She had long-continued 
and incessant vomiting. For many weeks she took no food, although 
with little if any emaciation. She had hemiplegia, palpitation, rapid- 
ity of pulse, constipation, tympany, and retention of urine, and these 
symptoms succeeded one another or were present in various combi- 
nations. But the most prominent symptom was a spasmodic and 
unceasing cough, so loud as to be heard through the house ; indeed, I 
have often heard it at the gate of the hospital. This was attended by 
frequent attacks of stridor — so severe as to threaten life — and these 
would alternate with convulsions, or some other symptom. During 
the latter the stridor would completely disappear. Many months 
passed by, during which this girl left and was readmitted into hospital 
on several occasions. Soon after her last admission she showed for 
the first time symptoms of fever, which eventuated in an attack of 
general though modified smallpox. During the continuance of this 
attack all the hysterical symptoms completely subsided. Some weeks 
elapsed, during which she continued well, when the tussis ferina and 



OUTBREAK OF HYSTERIA. 177 

the fits of stridor returned exactly as before. We looked on it simply 
as a renewal of the old condition, and, as many and various remedies 
had been tried before, the case was regarded as one which might be 
left to nature. In a few days she died, asphyxiated. On dissection, 
to our surprise, we found a great amount of inflammation and deep 
ulceration of the larynx, with total destruction of its ventricles. 

I do not think highly of that man's mind or heart to whom the death 
of a poor patient with recent, unrecognized, and probably remediable 
disease is a matter of indifference. Did the ulcerative disease coexist 
with the hysteria? It is not likely that it did, for the latter was of 
long continuance, while this laryngeal ulceration was obviously acute. 
Were its symptoms occasionally suspended during the convulsive 
paroxysms ? Did the variolous disease, by its derivation, cause a lull 
in the laryngeal condition, or did the hyperassthetic state of the larynx 
predispose it to organic change consequent on the exanthem? Un- 
happily we cannot solve these questions now, but there is one lesson 
to be learned from this sad case, and it is this: that, in dealing with 
hysterical patients, we must not fall into the common mistake of 
considering their local symptoms as in all cases unconnected with 
organic disease. 

We are not, then, to neglect local symptoms, and to consider them 
as merely neurotic in the hysterical condition. That they may he, 
and commonly are so, is certain, especially in cases of chronic disease. 
But in an acute disease like fever the occurrence of hysteria should 
make us especially cautious in our prognosis as to coming nervous 
symptoms. The late Dr. Oheyne, of this city, used to say that the 
hysterical complication was a ground of a good prognosis in every 
disease, fever alone excepted, and this observation may apply to all 
forms of essential and of symptomatic fever. 

Some time ago we had a remarkable manifestation of the hysterical 
state in fever. A young woman who was all but convalescent, and 
who had nearly passed through her disease before admission, was 
suddenly attacked with violent pain in the belly, which was swollen 
and tympanitic, with extreme hyperassthesia on pressure. But the 
corresponding symptoms of peritonitis were absent. There were loud 
and constant screaming and all the other evidences of a violent hys- 
terical attack. In the course of two or three days five other patients 
in the same ward became successively and similarly affected, and you 
can well imagine the scene presented by six women in the same ward 
and for several days and nights in this state. It seemed as if they were 
possessed, and labouring under the most violent form of demoniacal 
mania. There was nothing remarkable in the character of the fever 
12 



178 LECTURES ON FEVER. 

at the time. Some of them had simple continued and others typhus 
fever. Convalescence followed in all the cases, though in two of them, 
and in one especially, symptoms of enteric inflammation supervened, 
and were met by the usual treatment. 

These facts show how even in a fever ward hysteria will spread by 
contiguity. 

The most common form of the combination of the hysterical state 
with fever is met with generally in an advanced stage of the disease, 
when the patient shows signs of the hysterical state by complaining of 
anomalous symptoms, the alleged severity of which is in no way in 
accordance with the constitutional condition. She becomes unrea- 
sonable, capricious, and complaining. She watches for sympathy, re- 
fuses sustenance, and may be detected in feigning symptoms. Re- 
tention of urine is common, so as to require catheterism — an operation 
which should be, if possible, performed by a female attendant. 

But it is in cases where the nervous symptoms which properly belong 
to fever are preceded by a well marked hysterical state that head 
symptoms of a severe kind may be anticipated. In one of the most 
severe cases of typhus fever with cerebral symptoms that I have seen, 
the patient, a middle-aged man, of excellent physical development 
and the most splendid intellectual attainments, exhibited perfectly 
formed hysterical symptoms for thirty-six hours after sickening of 
fever. Symptoms of violent head-affection then set in, which were 
treated by local depletion. The case terminated favourably. 



PART II. 

TREATMENT OF FEVER. 



LECTURE XXV. 

Introductory Remarks — Principles on which the treatment of fever is to be based — 
True meanirig of the word empiric. Historical retrospect — The Symptomological, 
the Anatomical, the Rational or Eclectic Schools — Essence of fever cannot be de- 
termined by pathological anatomy — Etiology of fever is indefinite. 

Before entering on the treatment of fever it may be well to consider 
the principles on which it is to be based, and which the best physicians 
from the earliest times have followed. Though the application of 
these principles has varied according to the prevalence of this or that 
theory of disease, still, when we look at the recorded experience of 
practical men, we shall find that there has been in the main an agree- 
ment as to questions of prognosis and of treatment. Notwithstanding 
all that has been done in the morbid anatomy of fever, including the 
results of the microscope and of chemical research, I believe that our 
predecessors were, as a r.ule, as good physicians in fever as we are 
ourselves. Indeed, it may be held that in the highest quality of the 
medical mind, the almost intuitive perception of what is right to do 
under existing circumstances, they were — notwithstanding all our 
boasted advance in pathology — our equals, if not our superiors. The 
older British physicians — Sydenham, Haygarth, Heberden, Fordyce, 
and Fothergill in England; Gregory, Cullen, and Alison in Scotland; 
and Harvey, Cheyne, and Graves in Ireland — were all great physicians, 
whose practice was based on a study of the history and symptoms 
rather than the organic changes. These true lights of medicine were 
eclectics, and so were not wedded to any exclusive doctrine or practice. 
As I have said before, they were more symptomatologists than morbid 
anatomists — that is, their practice was founded rather on the general 
vital conditions than on the supposed state of any particular system. 
They looked on a case of fever as a whole, and dealt with it as a whole. 
They did not, like Paracelsus, advise their followers to burn the 
writings of Hippocrates, Galen, and Avicenna; or, like Broussais and 



180 LECTURES ON FEVER. 

some more modern professors, impugn the morality or the intellectual 
powers of the great men who preceded them. 

The class of physicians to which I allude did not assume any dis- 
tinguishing name. They were all imbued with the modesty of science, 
and did not affect to be the apostles of any new doctrine. They were, 
however, agreed on some great points, of which that of essentiality of 
disease was the chief one. This view of fever is well expressed by For- 
dyce, whom I have long since quoted in speaking of fever. "Fever," 
he says, " is a disease which affects the whole system ; it affects the head, 
trunk, and extremities; it affects the circulation, absorption, and the 
nervous system; it affects the body and it affects the mind: it is 
therefore a disease of the whole system in the fullest sense of the term. 
It does not, however, affect the various parts of the system uniformly 
and equally, but, on the contrary, sometimes one part is more affected 
than another." 

AW the great observers whom I have enumerated believed — and 
acted on that belief — that our knowledge of the nature of fever is of a 
negative character, and though the earlier of them did not fully appre- 
hend the history of the organic secondary lesions, yet it can be in- 
ferred from their writings and their practice that they looked on them 
less as the cause than the consequence of fever. To all intents and 
purposes, then, they recognized what we now call the secondary 
affections of fever, and met them as they arose, always keeping in view 
the previous and associated constitutional state so commonly marked 
by prostration of nervous energy. They recognized the laws of 
periodicity. In a word, their principles of management of fever were 
based on "observation rendered fruitful by study;" the recorded expe- 
rience of the past was to them a light in the wilderness, not a matter to 
be ridiculed or sneered at; and so, though unassisted by the scalpel, 
the microscope, or chemical research, they worked out the true prin- 
ciples of treatment by studying the living rather than the dead. Their 
treatment has been called empiricism, as if this term was necessarily 
one of reproach. 

I address myself now to the junior members of this class. I wish 
to impress upon them that those who so use the term display igno- 
rance alike of its meaning and of its derivation. The class of men of 
whom I speak practised empirically — that is, they practised from ob- 
servation and experience. Their empiricism was an enlightened empiri- 
cism, based on a just appreciation of facts as regards the living, rather 
than of those concerning either post-mortem changes or therapeutic 
influences. In truth, the term empiric has been applied to one who 
is truly not an empiric — to one who, ignorant of the natural history 



TRUE EMPIRICISM. 181 

of disease and of the influence of his so-called remedies on the health 
or life of his patient, practises recklessly and for his own profit, not for 
the benefit of the sick. To such a class the old-fashioned word " quack" 
applies, rather than that of " empiric." You may ask me : Are we all 
to be empirics? 1 answer: Yes, in the true sense of the word, for the 
benefit of our patients, not ignorantly or for our own advantage. The 
great men whose names I have mentioned were empirics of this kind. 
They had learned from long experience that the adoption of certain 
modes of treatment, differing according to circumstances, would be 
attended with beneficial results, although even the most gifted of them 
could not tell why it was that such effects were produced. 

All they professed to know was that such was the fact, and the line 
of treatment was adopted simply because it was proved to be useful. 
This was pure empiricism ; but who will refuse to say that the practice 
of it was not only justifiable but commendable? In fact, in the 
present state of medical knowledge we must all be more or less 
empirical in our practice. The gentleman who has the case of dumb 
ague under his charge in the wards prescribed cinchona, and therefore 
is an empiric; for he cannot explain, any more than I can myself, 
why the remedy is useful in such cases. He knows only that cincho- 
na exerts a specific remedial effect on the disease, and so he employs 
it empirically, yet conscientiously and wisely. 

The symptomological school of physicians in their treatment of 
fever invariably looked to the general condition of the patient first, 
and afterwards to the state of his local organs. And so these men, 
acting mainly by the light of their own genius, sagacity, and experi- 
ence, adopted the same principles of treatment which we advocate 
here, and which are now endorsed by the best men in Europe, aided 
as they are by all the appliances of modern science. These old physi- 
cians, to use the impressive words of Dr. Graves, "fed fever" liberally, 
yet judiciously, with nutriment, with wine, with tonics, and with dif- 
fusible stimulants. 

We now come to a school of practitioners who adopted a diametri- 
cally opposite plan of treatment in fever, who looked less to the pa- 
tient's general condition and more to the secondary and local affections 
of the disease under which he was suffering. They discovered, or 
thought they discovered, cerebritis, gastritis, hepatitis, pneumonia, and 
so on. according as symptoms arose indicative of engagement of the 
brain, the intestinal or the respiratory system; and they asserted 
that those physicians who dared to treat such symptoms of local in- 
flammation by the administration of food, wine, and bark were nothing 
short of privileged assassins, to be denounced as legalized murderers. 



182 LECTURES ON FEVER. 

Shortly after my election to this hospital, at a time when the fever 
wards were under the charge of Dr. Graves, a gentleman fresh from 
the schools of Paris, an ardent believer in the so-called physiological 
doctrines of Broussais, called on me to say that he could no longer 
continue to attend in the fever wards. I asked his reasons for this 
determination. He said, "I cannot longer witness such wholesale 
murder. I every day see Dr. Graves, in manifest cases of gastro entente, 
administering wine, brandy, and nutritive food, when the tongue is 
red and all the symptoms of enteric inflammation are present." "Bat," 
I said, "when you speak of 'wholesale murder' have you seen any 
cases in which this practice had fatal results?" "No," he replied; 
" that's the extraordinary thing ; but I suppose your Irish constitutions 
are peculiar. Yet I cannot bear to see it any more ; I must go away." 
And so this fettered doctrinaire lost the clinical teaching of the " great 
Dublin practitioner," as Graves was called by Trousseau many years 
later. 

This second school of physicians we may fairly designate "The 
Anatomical School," who denied essentialism and mistook the effect 
for the cause, and whose simple treatment was starvation and local 
depletion. I may here observe that the practitioners of this class 
used to style themselves " The Physiological School," but their physi- 
ology was very bad indeed. They based their theory and practice in 
fever on morbid anatomy rather than on pathology. They sought 
to explain all the symptoms of the disease, local and general, by re- 
ferring them to the sympathies of a part of the digestive system when 
under inflammation ; while they failed to recognize that this inflam- 
mation was not the first link in the chain of morbid phenomena, but 
was reactive and secondary in its nature. 

"We now come to the Rational School, though its disciples have not 
assumed any such distinctive name. It might be termed " The Patho- 
logical School," for pathology signifies only the physiology of disease. 
It is this school, shadowed out by the old English writers, still more 
developed by John Peter Frank, its views and doctrines long taught 
by Graves, which has been now followed by most right-thinking men 
at home and abroad. It is in this school that so man}' of our country- 
men have been educated, who in various parts of the world have so 
nobly upheld the repute of British and Irish medicine. It may be 
termed "The Eclectic School," for it adopts whatever is true in the 
teaching of the past, and rejects whatever is mischievous, erroneous, 
and bad. It admits the essentiality of fever — that strange but gen- 
eral condition which — it cannot be too often repeated — differs from 
any other condition of the living body, varying in form, in intensity, 



QUESTION OF ANATOMICAL CHANGES. 183 

duration, and secondary complications, subject to the laws of perio- 
dicity, and in which the rules of diagnosis of local diseases applicable 
in other cases must be modified. 

Now, if we inquire to which of the preceding schools, the sympto- 
mological or the anatomical, the present rational or eclectic system 
more nearly approaches, you will find that it is far more closely 
related to the first than to the second. In the present healthier state 
of medical opinion, the general condition of the patient in fever is 
looked on as of more importance than the local affections. "The whole 
is more than the pari 1 ' 1 is the golden principle to be recognized in the 
treatment of all essential diseases. You are not to adopt any exclu- 
sive theory from the condition of one part, and you are never to per- 
mit the occurrence of a local affection to sway you overmuch in your 
management of the general disease, if from your knowledge of the epi- 
demic character and the actual condition of the patient, you deter- 
mine that a decisive mode of treatment is necessary — for example, the 
use of food and stimulants. You are not to be stopped from giving 
them because some local affection might seem to prohibit their use, 
for I believe in ninety-nine out of a hundred cases you may override 
this seeming objection with safety and advantage. 

The anatomical school, as I have shown you, fell into the great error 
of regarding the local diseases in fever not only as primary but as 
necessary affections. You are to hold a diametrically opposite 
opinion ; it is in the higher knowledge of the laws affecting the local 
diseases in fever — its consequence, not its cause — that the rational 
and eclectic school has its chief merit. We of that school know well 
that, although these local diseases are so common that their occur- 
rence is the rule rather than the exception, yet they vary according 
to many circumstances. Some of these are utterly unknown to us, 
while of those the existence of which seems probable — such as climate 
and epidemic influence — the modus operandi is hidden from us. 

I have shown you that the so-called anatomical or physiological 
school explained the various symptoms in fever on the principle of 
organic sympathies, but they cannot be thus accounted for. Fever 
may exist without the presence of any notable anatomical change. A 
single case of this kind would overturn the entire theory, and 1 believe 
that the more you see of fever the more readily will you admit, 
especially in typhus, that the severity and the mortality of the disease 
are directly in proportion to the toxic effect of the poison and the 
freedom from anatomical change. 

I have brought before you examples of the cessation of fever coin- 
cident with structural change. The general principle which comes 



184 LECTURES ON FEVER. 

into view on looking at the most wide-spread epidemic affections is, 
that their victims do not die of local organic disease; or, to put it in 
other words, that the destructiveness of these affections is in the in- 
verse ratio to the amount of anatomical change produced by them. 
If this be so, it furnishes a crushing argument against the anatomical 
theory of fever, and recommends to our minds the paramount impor- 
tance of considering the vital rather than the organic state. 

One more important consideration I beg to recommend to you. 
The anatomical school held that between the local affections in fever 
and idiopathic inflammation there was no difference, but we hold fast 
to the opinion that, though similar in physical signs and in anatomi- 
cal character— at least to a great degree — to primary disease, they are 
widely distinct in their vital characters. Although to the eye, even 
when armed by the microscope, the character of these secondary 
changes may be precisely similar to those of idiopathic lesions, yet 
similarity of physical aspect by no means implies identity of vital 
character. Consider two cases of iritis apparently the same: you 
have an opportunity of examining the structures after death ; will you 
then find an anatomical difference between the two? Or if you do, 
will this explain the fact that in one case simple antiphlogistic meas- 
ures would suffice to subdue the disease, while in the others a specific 
treatment is necessary ? 

Gentlemen, you will perceive the vast importance of recognizing 
the vital characters which are extended to the products of disease, 
and this applies to all physiology. 

In Goethe's drama of Faust the Devil possesses himself of the pro- 
fessor's gown, and sitting in his chair is consulted by some of the 
students as to their objects of study. He decries anatomy as a means 
for clearing up the problem of life. I have often thought that the 
words of the great German poet and philosopher, which I have pre- 
viously quoted, are strangely applicable to the question of the vital 
character of disease, which is something varied, although hidden, not 
to be seen, measured, weighed, or analyzed. 

Before passing now to speak of the treatment of fever in detail, I 
would remind you that we cannot by pathological anatomy determine 
the essence of fever. We may even go further and say that no post- 
mortem or ante-mortem investigation has discovered what is its cause, 
why this condition presents itself in so many forms — some of them 
sufficiently distinct and, as it were, concrete, others more or less inde- 
finable — one form passing into another, varying at different times in 
history, apparent exciting cause, epidemic character, degree of conta- 
giousness, mortality, and the amount and nature of the secondary 



NO SPECIFIC TREATMENT. 185 

changes. It may be that destitution has been often attended with, re- 
lapsing fever, that decomposing human exuvise may induce typhoid 
or enteric fever, that typhus springs from overcrowding; yet I would 
exhort you to avoid all exclusive doctrines as to fever, whether you 
deal with its exciting causes, its classification, its pathology, or its 
results. 

As far as we can judge, the relation between the particular form of 
fever and its apparent exciting cause is by no means constant. Desti- 
tution is followed by every form of fever. The presumed exciting 
causes of typhoid — such as impure water, defective drainage, putrid 
emanations — will be followed by typhus in one case and by typhoid 
in another. While saying this, I believe it to be sufficiently made 
out that typhus is more immediately connected with overcrowding than 
typhoid, and that the latter form of fever is more related to the defective 
sanitary conditions I have just specified. But all this has little to do 
with treatment, the great principles of which are constant, while their 
application varies in the individual case or in the special epidemic. 



LECTURE XXVI. 

No specific line of treatment — Respect to be had (1) to the essential disease, (2) to 
its local and secondary effects — Failure of specifics in early stage of fevers — Want 
of success in the endeavour to found a science of therapeutics on experimental 
physiology or pathology — Effects of the action of the law of periodicity wrongly 
attributed to the adoption of therapeutical measures — Sustenance by food and 
stimulants — Two sources of danger to the fever patient; (1) primary effects of the 
fever poison in causing depression, (2) supervention of secondary local disease — 
Views of Dr. Graves on the subject of giving food in fever. 

In our study of the treatment of fever we shall best consider the 
question first in regard to the essential element of the disease, and 
next in reference to its local and secondary effects. You will meet 
with a certain number of cases in which your attention will be com- 
pelled more especially to the constitutional state, and this throughout 
the whole course of the malady; while even in the most prominent 
local complications you are not, in your treatment and prognosis, to 
overlook the essential condition. Lot us apply ourselves to the first 
of these questions. 

Is {"ever, independent of local complications, a condition which can 
be cut short, or can its duration be materially abridged ? In other 
words, is there any known specific treatment for any kind of con- 



186 LECTURES ON FEVER. 

tinued fever? — has any means been discovered of cutting the process 
of fever short, or of anticipating the time when, by the law of period- 
icity, the peculiar condition of organic life which we call fever will 
cease, and the system be again governed by its natural laws? 

Now, I believe that no direct or specific treatment which would 
have these effects has been as yet discovered. When 1 was a younger 
man, some idea that a fever might be cut short, particularly if it were 
dealt with in its earlier periods, influenced most, or at least many, 
practitioners. Each physician had, according to the teaching he had 
received or to the theories he had formed — less from experience than 
from a priori reasoning — his own favourite and routine method of 
proceeding. Some employed emetics to effect the object in view; 
others, diaphoretics ; many used purgation, blood-letting, or even the 
exhibition of mercury, while each appealed to examples of recovery 
after such proceedings in justification of them. 

I believe that all these courses of proceeding were not only futile, 
but harmful — futile in this, that they did not arrest the fever, and 
harmful because their effect too often was, in ordinary words, to spoil 
the case : that is to say, to interfere with the pathological laws which 
govern disease as physiological laws govern health. Among these 
laws that of periodicity is chiefly to be mentioned. There were other 
bad effects. Copious sweating or venesection produced debility. Pur- 
gatives predisposed, as we have seen, to dangerous disease of the di- 
gestive tube, while the use of mercury, especially in rheumatic fever, 
clearly increased the cachectic and anaemic condition in convalescence. 
Some of the worst cases of recovery from rheumatic fever which I 
witnessed were those in which the system had been saturated with 
mercury in the early stages of the disease. 

The error involved in the adoption of any of these practices was 
that of not recognizing the natural history of fever. These men acted 
vigorously in the first period of the disease, and thereby commonly 
tended to exhaust the system, not knowing what the duration of the 
case might be, when all the powers of nature would be called on to 
induce a favourable result. You, gentlemen, have not had an oppor- 
tunity of becoming practically acquainted with what I am about to 
tell you. It often happened that, after the employment of some of 
these measures, a remarkable lull in the symptoms followed ; the febrile 
state was greatly ameliorated and sometimes almost disappeared, the 
patient expressed relief, and everything seemed to justify the course 
which had been adopted. But the "snake was scotched, not killed," 
and in a short time the disease showed itself again, running its course 
unaffected — except for evil — by what had been done. 



FALLACY IN THERAPEUTIC RESEARCH. 187 

I have spoken of rheumatic fever. See the number of specifics 
that have been proposed for its treatment — mercury, opium, bark, iron, 
alkalies > acids, and so on. I will say nothing of the system of Bouil- 
laud — the bleeding coup sur coup. The very number and variety 
of the so-called specifics for the disease leads to a conviction of their 
little value as remedies. But it would be well were their effects only 
negative, for experience shows that they are too often injurious by 
their interference with, the ordinary and normal laws of the disease. 
As I have just said, rheumatic fever was commonly treated by mer- 
curialization, with the result that convalescence was in almost every 
case protracted and uncertain. 

In truth, gentlemen, that part of medicine which involves therapeu- 
tics has always been — and we may say, is still — in the most unsatis- 
factory condition. There is no part of medical science in which the 
principles of right reasoning have been so largely and so continu- 
ously neglected or outraged ; and though in our own time experimental 
physiology or pathology has been had recourse to as a basis for a ra- 
tional therapeutical science, yet how very far are we from any satis- 
factory conclusion on the matter? This is to be accounted for from 
various reasons. Experiments have been made on animals, and the 
results have been held to apply to man, not only in his normal but 
in his diseased condition. For example, to determine whether a mer- 
curial is ever efficacious in bilious derangement, calomel is given to 
a dog, in whose gall-bladder an open fistula has been made; and the 
question of its fitness in man, when in disease, is tested by the quantity 
of bile which flows from a canula in the gallbladder of a healthy dog. 

But it is in relation to our immediate subject, and especially to the 
periodicity of disease, that the most fruitful source of error in modern 
therapeutics exists. The essential disease, as well as its secondary 
effect, is subject to periodic law. Both spontaneously subside, and 
when that subsidence follows on the exhibition of this or that remedy, 
a therapeutic fact is held to be discovered. Yet this subsidence may 
be in no way connected with the effect of the remedy. It probably 
would have occurred without it; it may have been delayed or other- 
wise interfered with by the action of the medicine itself; nay, further, 
the subsidence of the essential or of the local part of the disease will 
occur even after the use of many and different remedies. The false 
reasoning which has been held to apply to one applies equally to all, 
and so the therapeutic experiments lead to erroneous conclusions. 

I have shown you that the study of the diseased or healthy organ- 
ism reveals more of the effects than of the essence of disease. Hence 
you must be cautious in adopting any therapeutical system based 



188 LECTURES ON FEVER. 

upon visible organic change. In the study of therapeutics we should 
depend principally upon experiment and induction in disease as ob- 
served in man. Professor Acland has observed that if but a few well- 
instructed men were to take up any one remedy, and continue to 
record the character and history of the case, and the results of the 
particular agent, making as it were their hospitals medical observa- 
tories, we should in time have such a mass of facts— the results of un- 
biassed observation — as would enable us to draw safe conclusions. 

The therapeutist of the present day has great advantages over his 
predecessors, particularly in the assistance which is now given by 
chemical and microscopical research. But he must also possess as- 
sistance of other kinds. He must know the principles of accurate 
reasoning, he must deal with vital phenomena, of which our know- 
ledge is so deficient that we have to study their modifications experi- 
mentally, as yet without any direct reference to structure or to vital 
chemistry. 

The laws of periodic action must be considered, and — as he pro- 
ceeds — he must inquire whether the simplest local, as well as the 
most complex general, affection is not more or less subject to some of 
these wonderful laws. He must study the question how far medical 
interference is capable of extinguishing morbid action, of merely post- 
poning it, or, lastly, of deranging a process which was to end in its 
removal. He must well understand how certainty in medicine is to 
be approached only by the balance of probabilities, and he must be 
thoroughly acquainted with the difficulties which are involved in those 
medical statistics which result from the labours of more than one 
observer. Other circumstances will suggest themselves — such as 
locality, race, habit, age, sex, and previous history. 

In dealing with the treatment of fever, and looking upon the disease 
in its aspect of essentiality — that is, as a condition independent of 
local disease and capable, after a period, of spontaneous disappear- 
ance — the question of the use of sustenance by food or stimulants 
should first engage our attention. 

We have seen that there are two prominent sources of danger to 
the patient in fever — one, exhaustion from the direct influence of the 
fever poison in depressing the vital energy ; and the other, the frequent 
development of local disease. But we are never to forget that when 
fever assumes the typoid form its duration is very uncertain. It may 
last from three to six weeks, so that if the sustenance of the patient 
be not attended to he may sink from inanition. On this point you 
should read Dr. Graves' ninth lecture, in which he teaches how to feed 
a patient in fever. I remember ouce, when he and I were going 



CHOICE OP FOOD IN FEVER. 189 

through the convalescent wards, he expatiated on the healthy appear- 
ance of the patients, many of whom had gone through long fevers. 
"This is all owing to our good feeding, " he said. " Will you, when 
the time comes, write my epitaph, and let it be — 'He fed fevers'?" 

Now, this expression of one who was the representative man in 
medicine in Ireland has been carped at by some of those whose criti- 
cism means only fault- finding — a wide-spread class like the critic in 
Goldsmith's Citizen of the World. " The work might have been better 
if the artist had taken more pains." It has been supposed that Graves 
advocated high feeding in fever indiscriminately, but you know too 
much to believe this. lie speaks of the danger of the starving system, 
and shows how the practice arose from the doctrines of those who 
taught that fever was only symptomatic of inflammation. He shows 
the effect of abstinence in producing symptoms similar to those of 
the worst fevers, as exemplified in the wreck of the " Alceste" and 
of the " Medusa." " You may," he says, " think that it is unnecessary 
to give food, as the patient appears to have no appetite and does not 
care for it. You might as well think of allowing the urine to accu- 
mulate in the bladder, because the patient feels no desire to pass 
it. You are called on to interfere, where the sensibility is impaired, 
and the natural appetite is dormant; and you are not to permit your 
patient to encounter the horrible consequences of inanition, because 
he does not ask fur nutriment. I never do so. After the third or 
fourth day of fever, I always prescribe mild nourishment, and this is 
steadily and perseveringly continued through the whole course of the 
disease." 

He continues: "An attentive consideration of the foregoing argu- 
ments has led me, in the treatment of long fevers, to adopt the advice 
of a country physician of great shrewdness, who advised me never to 
let my patients die of starvation. If I have more success than others 
in the treatment of fever, I think it is owing in a great degree to the 
adoption of this advice. I must, however, observe that great dis- 
crimination is required in the choice of food. Although you will not 
let your patient starve, do not fall into the opposite extreme: you 
must take care not to overload the stomach. When this is done, 
gastroenteric irritation, tympanites, inflammation and exasperated 
febrile action are the consequences. I have witnessed many instances 
of the danger of repletion in febrile diseases. A case of this kind oc- 
curred some time ago in this hospital, in a boy who was recovering 
from peritonitis. \n another case, in private practice, an incautious 
indulgence in the use of animal food was followed by a fatal result. 
A young lady ate some beefsteak, contrary to my orders, at an early 



190 LECTURES ON FEVER. 

period of convalescence from fever, relapsed almost immediately, and 
died of enteritis in thirty-six hours." 

He then speaks of the care and judgment which are necessary in 
giving food, particularly in the beginning of fever. He recommends 
well-boiled gruel made of groats and flavoured with sugar, thin pa- 
nado, and, as the fever advances, speaks of good and well-made chicken 
broth as one of the best of nutriments — to be employed, however, at 
first experimentally. He advises that. " all kinds of food and nutri- 
ment should be given by day, and the patient should, if possible, be 
restricted to the use of fluids by night. The natural habit is to take 
food by day and not by night, and in sickness as well as in health we 
should observe the diurnal revolution of the economy." Again, the 
usual period of meals should be observed, and the space of time for 
giving chicken broth, jelly, arrowroot, and other mild articles of diet 
should be from eight o'clock in the morning to eight in the evening. 

With respect to drinks, he considers that the patients are generally 
allowed to drink too much. "It may be urged that they have a 
strong desire for fluids; but they should not be gratified in everything 
they wish for. The continued swilling of even the most innocent 
fluids will bring on heaviness of stomach, nausea, pain, and flatulence, 
and predisposes to congestion and intestinal irritation." Further on 
he says: "You should never allow them to take a large quantity of 
fluid at a time; you should impress upon them the danger attendant 
on such a practice, and tell them that a spoonful or two, swallowed 
slowly, allays thirst more effectually than drinking a pint at a time." 
Again: "The abuse of ordinary drinks — as common water, whey, 
barley water, soda and seltzer waters, and effervescing draughts— is a 
frequent source of tympanitic swelling in fever." 

I have now shown you that Dr. Graves was no advocate for the in- 
discriminate and too liberal employment of food in fever, and that he 
was fully alive to the dangers both of the want and the excess of food 
even in convalescence. 

In addition to the prejudices with which the inflammatory doctrine 
imbued so many minds, with respect to the use of food in fever, a 
new set of arguments was raised against it, in consequence of the ex- 
periments of an American physician. I allude to the case observed 
by Dr. Beaumont, and so often quoted since. In this remarkable case 
various medicinal substances and articles of food were introduced 
through an external fistula into the stomach; their effects were noted, 
and also the conditions of temperature, vascularity, etc. The results 
were subsequently published in connection with the action of the sto- 
mach upon food. One of the results stated to have been thus obtained 



DIGESTION IN FEVER. 191 

was, that the existence of the state of fever altogether suspended the 
process of digestion. Here was a statement which had the appearance 
of being founded upon strict observation. It influenced a number of 
young men ; but did it influence those who had once been in charge of 
a fever hospital ? Not at all ; because such men knew well that, no 
matter what Beaumont might say about the stomach not digesting 
when the patient had fever, in thousands of cases patients in fever 
digested remarkably well, required food, and derived benefit from it. 
In a large number of cases of typhus fever the stomach has an excel- 
lent power of digestion; and, I believe, if we were bold enough, we 
should find that many articles of food usually forbidden to fever 
patients might be given to them with safety. 

A remarkable incident was related to me which shows that the sto- 
mach in fever is capable of digesting even a rather coarse article of 
food. A lady who had been recently married was attacked with ex- 
tremely severe petechial fever ; she was covered with dark-coloured 
maculas, and disease had run to about the twelfth or thirteenth day. 
She was attended by several eminent physicians. Her case w r as an 
extremely bad one, and her life was all but despaired of. She was 
violently delirious. Her husband, himself a physician, had occasion 
to leave the house on some business. At the period of the dinner hour 
of the family the servants were cooking a rump of beef and cabbage, 
and the odour of it filled the house. In her delirium the patient 
called for some of the dish. Her sister, who was attending her, be- 
lieving she was dying, determined to indulge her, from the feeling 
that it was right to accede to the request of a dying person. She 
proceeded to the kitchen, and, as soon as the beef was boiled, brought 
up a very large mess, smoking hot, to the lady's bedside, when she 
devoured it with great avidity. Shortly afterwards her husband 
came in, and was told what had happened. He became terrified, and 
sent for physicians in every direction. Four or five assembled ; time 
was pressing, and all agreed that something should be at once done. 

Each of these physicians had his own suggestion to offer — one re- 
commended an immediate emetic; another, a drastic purgative; a 
third, a purgative injection ; a fourth, a large dose of calomel ; a fifth, 
a powerful blister. At length the late Dr. Harvey, then Physician- 
General and a man of the greatest practical knowledge in medicine, 
joined the consultation, all members of which except himself were in 
a state of intense excitement. At the time the stomach pump was 
not in fashion, but every one agreed that some great effort should be 
made to get the corned beef and cabbage out of the lady's stomach. Dr. 
Harvey was entreated to go upstairs immediately to see the patient, 



192 LECTURES ON FEVER. 

who was declared to be in coma. His first observation was charac- 
teristic of the man. "Some of you," lie said, "help me off with my 
coat." He proceeded leisurely to the bedside, where he remained for 
some minutes, which appeared to the anxious consultants below an 
inordinate period of time. He came downstairs slowly, and on en- 
tering. the room was again surrounded, all of them declaring their 
willingness to forego their individual opinions and to abide by his 
decision, for not a moment further was to be lost. 

He was quite unmoved by the situation, and simply said, " By , 

I\\ let her sleep it out I" and took his departure. She did sleep it 
out, and in the course of some hours awoke much better. Her re- 
covery was perfect. 

Now, I do not tell you this anecdote to induce you to feed your 
patients with salt beef and cabbage in fever, but it is very important 
as showing that in the advanced stage of a maculated typhus fever the 
stomach is capable of digesting such an article of food as salt beef, 
and that it proved in the particular case innocuous. Dr. Harvey 
was too good a physician not to understand the evils of the nimia di- 
ligenlia medicorum in fever, and the result showed the value of his 
practical knowledge. The supposed coma was natural sleep — a most 
favourable circumstance, and he knew his art too well not to decry 
any interference with it. 

There can be little doubt that in many cases of advanced fever a 
greater latitude in the use of food might be adopted with advantage. 
But you must remember that, in the lower ranks of life, the power 
of the stomach to deal with a variety of food becomes less and less. 
Ordinary nourishment commonly answers well where greater delica- 
cies would be rejected or would disagree. 



STIMULANTS IN FEVER. 193 



LECTURE XXVII. 

Stimulants in fever — Views as to the nutrient properties of stimulants are to be 
received with caution — Anticipative use of stimulants — Meaning of the term — Con- 
siderations to be taken into account in resolving upon this method of treatment : (1) 
prevailing epidemic character of the disease, (2) previous condition of the patient 
(" Sinking of vital power" — Illustrative case — Stimulation often unsuccessful in the 
intemperate, and in those whose brains are overworked), (3) development of symp- 
toms of severe typhus, (4) development of fever odour — Contrast between typhus 
and typhoid as regards period at which stimulation is called for — Condition of the 
heart, a guide — Physical signs of cardiac weakening. 

Following- the consideration of food in fever we shall next take 
up that of diffusible stimulants. Their employment we have had to- 
gether a full opportunity of studying, and those of you who are prac- 
tising pupils have learned to prove their value and importance in 
every form of fever. You have learned also to avoid routinism, and 
you well know that when we speak of every form of fever we do not 
mean every case of the disease. We have had cases in which no 
wine was used, in which it was sparingly employed, where it was not 
used until after the middle period of the fever. In many cases, too, 
you had to use it and other stimulants with great boldness and for 
many days, beginning at an early stage of the disease. Again, wine 
had sometimes to be omitted, though the disease still was running on ; 
and, lastly, its exhibition or its withdrawal had to be alternated sev- 
eral times in the course of the disease. 

Many of you have also learned that in fever the common error of 
delaying the giving of stimulants to a very late period of the case is 
a practice fraught with mischief, attributable to the prevalence of the 
doctrine that fever and all its local symptoms were induced by in- 
flammation. By this system all the good of the anticipative use of 
stimulants is lost. 

Any unbiassed observer of fever will admit that between the con- 
dition of vital prostration and what is termed " waste of animal tissue" 
there is no constant relation. We cannot deny the occurrence of 
metamorphosis of tissue and waste of organic substance as incidental 
to fever; on the contrary, we believe that these phenomena are re- 
markably perceptible. But we must also hold that there is a prostra- 
tion of vital energy — a tiling per se } which is totally unconnected with 
loss of organic substance. Do not for a moment forget this — that the 
13 



194 LECTURES ON FEVER. 

forms of disease in which we find the greatest prostration of vital 
power are those wherein we discover least signs of organic mischief. 
A striking example of this is found in cholera, and in the various 
forms of continued fever. 

Now, I must tell you that the views of my lamented friend Dr- 
Todd are to be received with caution. One thing is certain — that 
whether we look on wine and brandy as food or simply as stimulants, 
the great point is to know when and how to administer them bene- 
ficially. We have not indeed attempted to decide the question ex- 
perimentally as to whether stimulants act as food by repairing the 
wasted tissues, for in all our cases food and stimulants were given to- 
gether — our object being rather to save life than to settle an abstract 
physiological question ; and many of you had cases of weakened heart 
in fever where the influence of stimulants was too rapid to be ac- 
counted for except on the principle of a direct action on the nervous 
system. 

It is true that we have seen life prolonged for several weeks by 
stimulants alone. Some years ago a patient in one of the small wards 
had long used a fabulous amount of spirits. He lived on brandy or 
whiskey for a month, during which time he swallowed nothing else, and 
cost the hospital a good deal more than his life was probably worth. 

If Dr. Todd's views were to be carried out in every case of disease, 
essential or otherwise; if, in short, we were to administer stimulants 
on the routine principle — regarding them as nutrient substances, cal- 
culated to supply the waste of animal tissue, and as it were rebuilding 
the organic structure, we should find ourselves lamentably disap- 
pointed. The adoption of such a system found very few supporters 
among experienced physicians. 

But let us do justice to Dr. Todd's memory. As practical men, in 
the present state of our knowledge, we have little to do with questions 
of physiology, and to him belongs the merit of showing that the use 
of alcohol may be resorted to or at least borne in states of disease 
where it was held to be dangerous. He has still further shown the error 
of the anatomical school, which referred everything in acute disease to 
inflammation ; and though he may have fallen into a routine practice, 
we should be slow in holding him answerable for the errors of some 
of his followers. 

Even in many essential diseases you will find that stimulants are 
contra-indicated or badly borne. I do not say that in such, an oppo- 
site mode of treatment will succeed, but there are many cases of es- 
sential disease — of puerperal fever, pyaemia, malignant scarlatina, small- 
pox, and others — in which, though the vital strength is fearfully pros- 



ANTICIPATIVE STIMULATION. 195 

trated, for some reason which we cannot explain stimulants are too 
often powerless for good. There can be no doubt that the efficacy of 
stimulation is closely connected with the prevailing epidemic character 
of disease, and thus it was observed in our late visitation of small- 
pox that wine and brandy were often productive of good effects. 
But still the proposition is true that stimulants in the class of diseases 
I have mentioned are not followed by the same happy and almost 
heroic effects which we so often witness in typhus fever. 

We may dwell upon the question of the use of stimulants in fever 
as regards, first, the anticipative treatment, and next the treatment 
urgently called for by the circumstances of the case. By the term 
anticipative treatment you are to understand the administration of stim- 
ulants at an early stage of fever, when, although there may be no 
very pressing vital symptoms calling for their use, the sagacity of 
the physician enables him to foretell the occurrence of great prostra- 
tion of vital energy. Under such circumstances he gives stimulants 
by anticipation. 

In comparing the relative value of these two modes of proceeding, 
I am of opinion that the anticipative method is that which will tend 
most to the saving of human life. In adopting this line of practice 
the physician does not wait until the patient has been labouring for 
many days under the exhausting influence of the disease. He does 
not withhold the needful aid until the 10th or 12th day, when the 
prostration of vital energy has assumed a formidable aspect, when the 
prompt use of stimulants is suggested by common sense, and when 
often, unfortunately, the system is incapable of responding to the 
remedy. For you will learn that where the powers of life have re- 
mained long without support, a downward process may commence 
from which no effort can rescue the sufferer. 

In the anticipative treatment we follow the old maxim, " venienti 
occurrite morbo," and he who knows when to adopt it has gained a 
high place in practical medicine. 

In determining on the employment or the contrary of the anticipa- 
tive treatment, the following considerations must be present to you 

First, the epidemic character or habit of the disease; secondly, the 
previous condition of the patient. 

What we have to guard against is a sudden sinking of the vital 
energy, shown by special conditions of the nervous and the circula- 
tory systems. I have told you, that, with respect to these and the other 
systems in fever where the strength has been unsupported, the down- 
ward tendency goes on until a point is peached from which there is 
no revival. In these eases there is between the heart and the nervous 



196 LECTURES ON FEVER. 

centres a great sympathy, and the condition of the one — which is re- 
vealed by manifest physical signs, and with which you are all now 
familiar — gives you a clear conception of the state of the brain and 
the spinal marrow. 

This failure of the heart, like the other secondary affections, is 
under the law of periodicity, yet I believe it may occur in chronic 
cases, but with this difference — that having become established it 
continues until the end. A gentleman of energetic and industrious 
habits, who lived well and took his bottle of wine daily, and who 
never showed any disease of the heart, became subject to attacks of 
ordinary gout. He was persuaded to undergo a protracted course of 
hydropathy, during which the candle was burned at both ends, for 
no wine or stimulant was allowed for more than a month. His con- 
dition was remarkable; he had no pains, no fever, the pulse was about 
sixty, weak but regular, and when asked to describe his symptoms he 
said, "I have no complaint to make, but of a strange weakness of 
body and mind which is quite new to me." He lived for several 
weeks, the failure of the heart increasing every day, while no amount 
of stimulation had any effect in restoring its vigour, and he died 
without any ascertainable cause beyond mere nervous exhaustion. 
The process of death was peculiarly slow. 

This sinking of the vital power, not accounted for by any apparent 
loss of organic tissue, takes place in fever, and it is with a view of 
arresting its progress that we have recourse to the anticipative treat- 
ment. But there are various grounds for adopting this line of con- 
duct; for example, if you know that in the epidemic, a great number 
of cases assume well-marked symptoms of prostration, say on the 
seventh, eighth, or ninth day, you will on the fourth or fifth anticipate 
their occurrence by commencing the use of stimulants. Even in the 
middle of the course of a fever case, or at any period of its progress, 
you will do right to guard against the occurrence of sudden prostra- 
tion, which, when once it has set in, especially in mature age, may 
resist the most active stimulation. 

But there are collateral circumstances to which you must look — 
such as the previous history of your patient, his habits of life, his 
previous health, in short, whether he brings into this contest with a 
formidable disease a constitution affected by previous illness, bad 
habits, or nervous exhaustion. You will also ascertain whether any 
ignorant attempts to cut short the fever had been made ; the patient 
may have been bled for supposed inflammation, he may have had 
cathartics, mercury, tartar emetic, or powerful diaphoretics. In such 
cases you have solid reasons for adopting the anticipative method, 



INDICATIONS FOR STIMULATION. 197 

though the patient may not as yet have fallen into a state of pros- 
tration. 

The fall administration of stimulants is generally called for when 
the patient has passed the age of eighteen or twenty. In children 
we are obliged to have recourse to stimulants, but we employ them 
in a modified manner; their energetic use is indicated principally 
in adults between the age of twenty-five and forty-five, and here we 
employ them at an early period, not so much to combat existing 
prostration, but to anticipate the depression of vital power which 
sooner or latter is almost certain to ensue. 

In estimating the chances that the employment of stimulants will 
be followed by success, much will depend on the previous habits of 
the patient. We have long found that the greatest triumphs of the 
stimulating treatment were seen in patients of strictly temperate 
habits, who seem more capable in fever of bearing large quantities of 
stimulants without intoxication. In private practice we often find 
that stimulation cannot be carried on so boldly as in hospital ; and 
this appears to be connected with the previous habits of the patient, 
not in the way of intemperance in the use of wine, but in that of over 
exercise of the brain. Men engaged in anxious callings, or in intense 
mental exertion, are bad subjects in fever, and bear the stimulating 
treatment imperfectly. Thus it is that professional men so frequently 
succumb — witness the frightful mortality among the medical men of 
Ireland in the famine fever. In many such cases, with symptoms of 
profound adynamia, stimulants are badly borne, and hence — when the 
disease, as too often happens, is of a malignant character — the patient 
makes but a poor fight, and adds to the list of victims who have fallen 
in the discharge of their duty. 

For the first few days your patient may make little complaint. 
There are often remissions in which he declares himself much better; 
but if the symptoms of essential fever are gradually developing them- 
selves, if petechial spots begin to appearand particularly if the skin 
exhibits the dusky discoloration so characteristic of typhus, you may 
expect severity of symptoms. This discoloration appears, and after 
a time recedes, as the petechia come and vanish, and like them too is 
subject to the law of periodicity. 

Another indication for the early exhibition of stimulants is the 
peculiar fever-odour sometimes present from a very early period. 
Benign fevers rarely are attended with this peculiar odour, which 
belongs to more malignant forms of disease. 

You will observe that the symptoms I have particularized are more 
closely connected with typhus and with typhoid fever, and- accord- 



198 LECTURES ON FEVER. 

ingly we find that early stimulation is much more frequently indicated 
in the former than in the latter; in other words, the free use of stimu- 
lants, when necessary, is called for at a later stage of the disease in 
typhoid than in typhus. It is right, however, for us to bear in mind 
that some of the cases requiring the most powerful stimulation have 
been of typhoid fever in its advanced and complicated condition. 

It is in petechial typhus that the anticipative treatment is most 
frequently called for, and will be found to answer best. In typhoid 
fever the occurrence of prostration is commonly later observed, and is 
of more gradual development. As we have already seen, this form 
of fever is less manifestly under the law of periodicity than true 
typhus, and the character of its secondary affections is more variable. 

Physicians have from the earliest times been in the habit of deter- 
mining on the administration or withholding of stimulants in fever by 
the state of the pulse. But — at least in the early periods of fever — 
the pulse taken alone is not to be depended on. It may be, up to the 
fourth day, full, throbbing, and resisting, and this has often led to 
errors in practice of both commission and omission. I have shown 
you that even under these circumstances an examination of the 
heart may reveal the commencement of a change in the vital condi- 
tion of that organ. It was this temporary excitement of the pulse 
that led to the practice of bleeding, and of employing other depleting 
measures, by which the vital power was expended at an early stage 
of the case, and the influence of the law of periodicity was interfered 
with. 

This ephemeral state of arterial excitement led, on the other hand, 
to errors of omission. The apparently inflammatory condition caused 
apprehension — the existing state was alone attended to, and the prob- 
able future in the case disregarded. You will not fall into these 
errors. The secondary debility of the heart may have commenced at 
a time when this pseudo-inflammatory state still existed, while in fact 
the pulse continued full and bounding, and the temperature high. 

Take this rule with you into practice — that in the treatment of 
fever, and at almost any period of fever, you are not to be guided by 
the pulse alone. It must be observed in relation to the action of the 
heart — remembering that a full and good pulse may coincide with a 
feebly acting heart — a heart under the influence of the fever poison, 
often as it were on its way to the state of softening. All this you see 
bears on the question of the anticipative treatment. 

Now among the most reliable indications for the early use of this 
treatment are the physical signs of weakness of the heart. 

A man, aged 30, was admitted on the sixth day of typhus fever. 



WEAKNESS OF THE HEART. 199 

He was the fifth of his family who within a short time had severe 
maculated typhus. The impulse of the heart was scarcely perceptible, 
and there was already a distinct preponderance of the second sound. 
On the next day the impulse was imperceptible, even when he lay on 
the left side. He was ordered twenty ounces of wine, a blister over 
the heart, and beef-tea. The following day the impulse could be felt, 
but the sounds resembled those of a foetal heart. The wine was 
increased, and two glasses of brandy were also administered. On the 
12th day the pulse had fallen to 80, and the sounds of the heart were 
greatly improved ; on the 13th day the impulse of the heart was re- 
stored, its sounds were proportionate, and the pulse had fallen to 76. 
The diminution of the first sound of the heart led us to the exhibition 
of stimulants boldly, and at an early period of the case. On the 7th 
day the impulse was imperceptible, while on the 8th the first sound 
had disappeared ; and although the other symptoms did not seem to 
call for active stimulation, wine was ordered in free doses from this 
indication alone. The symptoms of cardiac debility were observed at 
so early a period as the sixth day, but it is probable that the typhous 
affection of the heart had commenced even before admission to 
hospital. 

So far as the heart is concerned, the following are the physical signs 
which seem to indicate the anticipative use of stimulants. I have put 
them down in their chronological order: — 

(1.) Early subsidence of the first sound, observed over the left 

ventricle. 
(2.) Diminution of the first sound over the right ventricle. 
(3.) The heart acting with a single, and that the second sound. 
(4.) Both sounds being audible, but their relative intensity being 
changed so as to represent the action of the heart of a foetus 
in utero. 
(5.) With these signs, a progressive diminution of impulse, which 
occasionally becomes imperceptible, even when the patient 
lies on the left side. 
During convalescence, as we have seen, the signs of recovery of the 
heart are usually observed first on the right side, and afterwards over 
the left side. 

With reference to the anticipative treatment, we have spoken 
principally of the results of physical examination, as indicative of 
the typhous weakening of the heart in the early stages of fever. I 
have stated, that, although in the commencement of a typhoid fever 
any bold exhibition of stimulants is not often called for, yet in its 
advanced stages we have sometimes to make free use of stimulation. 



200 LECTURES ON FEVER. 

I have observed that students were occasionally under a misappre- 
hension about the doctrines which we have long held in this hospital 
with respect to the condition of the heart as a guide for the use of 
wine. They have come to the erroneous opinion that we are to give 
wine only when we find the want or diminution of the first sound of the 
heart, and that we are not to give wine where the heart is acting well. 
This is a mistaken view. As to the state of the heart in connection 
with the effect of stimulants, we have ascertained that the efficacy of 
stimulants is often directly as the debility of the organ. It has also 
been ascertained that the power of bearing stimulants, their effect 
upon the nervous system, their good effects on the general condition, 
are directly as the weakness of the heart. 

We may lay down as a rule, that there are three conditions of the 
heart to be looked at by the practical man in the treatment of fever. 

In one, we have an excited heart — a violently excited heart all 
through the case; and this, although the symptoms be those of extreme 
adynamia, although the surface be cold, the breath cold, and the pulse so 
feeble that it cannot be discovered. Nay, the heart may act with great 
force for several days, and yet there may be no pulse at the wrist. 
This is one case. 

In the next case, we find an exactly opposite condition, in which the 
systolic force of the heart is diminished. This is shown by loss of 
impulse, by diminution — and, in certain cases, by extinction — of the 
first sound of the heart, while the second remains. This is a case 
which calls for wine, and in which you should give it; it is a case in 
which, in the vast majority of instances, wine will agree with the 
patient. 

There is a third set of cases in which the heart does not seem to be 
implicated at all in the course of the disease — in which, notwithstand- 
ing the existence of the most extraordinary group of symptoms affecting 
various organs, the heart, in the middle of the storm, seems to be in a 
state of calm and quiet. 

If we compare these three conditions with a view to prognosis, we 
may arrange them in this way. The excited heart all through, with 
feeble pulse and with adynamia, is unquestionably the worst. There 
is no worse symptom in fever than an excited heart. It is especially 
a bad symptom when, with that excitement, we find a feeble pulse. 
Next will be the case of sinking of the heart ; and the most favour- 
able condition is that in which, as I said before, the heart seems to 
escape disease. 

You are not, however, to suppose that because you have an ex- 
cited heart you are not to give wine ; or that, because the heart is not 



STIMULANTS IN FEVEE. 201 

affected at all, you are to withhold wine if in either case the general 
symptoms of the patient require it. You are not to found your ex- 
hibition of wine or other stimulants upon any one thing; you are to 
take the general state of the patient into consideration. What we 
have done is to discover an intelligible practical rule which will 
guide you in the use of wine in certain, I think in many, cases; but 
you are not to suppose that because a man has a clear first sound of 
the heart, therefore you are not to give him wine. You are not to 
suppose that because the heart is safe you can do without wine. Now, 
in a case recently under your observation, although the heart seemed 
to escape, or was at most only feeble through the course of the dis- 
ease, frightful adynamia existed; day after day the patient's face was 
Hippocratic, or almost so ; the general character of the disease was 
that of the most terrible putrescent fever — yet his heart escaped. 
And here is the result. We have given that man upwards of twenty 
bottles of wine and twenty-four ounces of brandy, and now, on the 
twenty-eighth or thirtieth day of the disease, we have the satisfaction 
of feeling that his case may be set down as among the triumphs of 
medicine. 

I wish also strongly to impress on you the great importance of the 
use of other forms of nourishment in this disease ; for we must not 
only keep up the nervous energy of the system by wine, but we must 
support nature by food. There is no greater mistake in fever than 
that of the withholding; of food. 



LECTURE XXV ITT. 

Stimulants in Fever, continued — Signs in connection with the heart of the agreement 
of stimulants : (1) return of impulse, (i) return of first sound, (3) gradual fall hi 
the rate of the pulse— In cases of " foetal heart" great boldness in stimulation is 
Deeded — No certain rules as to quantity of wine and whiskey or brandy required — 
Examples of free use of stimulants in malignant typhus — Case of Hardoastle (ty- 
phoid fever) — Eruption of vesicles as a secondary complication — Bed-sores. 

We arc today to consider practically the use of stimulants in fever. 
This is a matter difficult to be taught orally. The exhibition and the. 
management of stimulants in ^cvcv are among those points in practice 
which are best learned at the bedside, so that when I am addressing 
the advanced students — men who themselves have already largely 
shared in the responsibilities of the fever wards — I do so as a fellow- 
student on the one hand, and a brother practitioner on the other. 



202 LECTURES ON FEVER. 

Many medical men who have received little beyond a surgical edu- 
cation, or who have not had a case of fever on their hands before 
they entered into practice, and who probably have never attended in 
the wards of a fever hospital, on their first meeting with the disease, 
are timid in the use of wine in fever, and have not learned that in 
this disease the symptoms of inflammation are commonly fallacious. 
This, as I have before said, is from the nature of their medical educa- 
tion. Here we see the wisdom of that regulation of the University 
of Dublin, in accordance with which all candidates for the degree of 
Bachelor of Medicine must show that they have personally attended 
at least five cases of fever before being admitted to examination. 

As experience increases, men become less timid in the use of wine, 
and accordingly we find that those physicians who are sneeringly 
termed men of the old school, are often the best practitioners in fever ; 
they have learned by experience in middle life what you have been 
taught in your student days, and they know, by their perception of 
the vital phenomena, when to give or not to give stimulants, when to 
increase, to diminish, or to omit them. 

Now it is a great thing to possess a simple rule which will guide 
the practitioner who has had little or no experience in this matter, in 
the exhibition of wine — and I believe that in the observation of the 
ph} r sical signs of the heart, he will obtain such assistance. You will 
not suppose that I advise you to be guided solely by the state of the 
heart, but I say that in solving the question as to the use and the 
management of stimulants, you are to ascertain and consider in every 
case the condition of the organ plus the general symptoms and his- 
tory. 

We have already studied the anticipative use of wine. Let us sup- 
pose we have a case of maculated typhus, say on the sixth or eighth 
day — the pulse not very weak, and at 115 or 125 in the minute; you 
find that the impulse is not strong, or it may be absent, unless when 
the patient lies on the left side — the first or ventricular sound is les- 
sened. Under such circumstances the use of wine is called for, and 
there is a strong probability that it will agree. You begin with six 
or eight ounces of good port in the day — given in divided- doses, 
together with proper food. 

It will always be right that in such a case you should see the 
patient in the course of six or eight hours, to judge whether the stim- 
ulant has agreed ; in a few cases even at this period of the fever the 
depression of the heart goes on rapidly, and if so, the stimulant will 
have to be increased. Should things on the next day remain without 
change, and should there be no signs of the stimulant having dis- 



AGREEMENT OF STIMULANTS. 203 

agreed, you may continue. By-and-by it may happen that the first 
sound of the heart disappears, so that the organ acts with a single 
sound, even over both ventricles. This indicates increasing debility, 
and calls for a free use of the stimulant, and, in many cases, the em- 
ployment of brandy, for which a good vehicle is warmed milk with a 
little sugar. 

Now, in most cases of typhus fever in this country with favourable 
result, the prostration of the patient, of which the heart is commonly 
so good an index, begins to disappear at about the twelfth day, but 
you may find evidences that the wine has agreed even before that 
period. Of these the principal are :— 

1st. The return of impulse. 

2d. The commencing re-establishment of the first sound. 

3d. The gradual coming down of the rate of the pulse. 

Of these, the second and the third are the most important, for the 
return of impulse is sometimes the commencement of an excited state 
of the heart— always an unfavourable symptom in fever. When the 
first sound is restored in its normal manner, the process is gradual, 
being commonly first perceived over the right ventricle, and when 
completed it has its natural character. 

But with regard to prognosis, the best indication of the agreement 
of stimulants is the lessened rate of the pulse; even a slight diminu 
tion, say of two or three beats in the minute, is of great importance. 
If -at your next visit the diminution of rate goes on, it is a great en- 
couragement to a good prognosis. Remember how often we have 
seen a good result when the only favourable point in the case was that 
the pulse became slower and slower while stimulants were being freely 
used. Still, to say that the falling of the pulse under stimulants is a 
certain ground for a good prognosis would not be justifiable, as Ave 
shall see presently. 

In cases of extreme nervous prostration and debility of the heart, 
as shown by the foetal character of the sounds — or in some instances 
by the extinction of all sound, while the pulse continues — great bold- 
ness may be used in the administration of stimulants. It is true that 
in examples of the "foetal" heart the ventricular sound continues. 
Yet we have found that the lessening of the second sound is an im- 
portant sign of generally deficient vital energy, and the necessity of 
free stimulation. Of this I offer no explanation, but of the fact I am 
certain. 

It is very difficult to lay down rules as to the quantity of wine or 
other stimulants that may be required by circumstances, and you 
have seen cases in which the patients took a quantity of stimulants, 



204 LECTURES ON FEVER. 

which in the state of health would have produced intoxication. We 
have commonly given from 16 to 21 ounces of wine with half a pint 
of brandy in the day; and in many cases we might have given more, 
and with advantage. 

In a severe case of maculated typhus with extinction of the first 
sound over both ventricles from the seventh day, 96 ounces of wine 
with five ounces of brandy were exhibited. The coming down of the 
pulse was remarkable. 

Thus on the 7th day it was at 124 
8th " 120 

11th " 116 

12th " 96 

18th " SO 

15th " 76 

On this last day the skin was cool, the impulse perceptible, and the 
sounds proportionate. 

This case also showed that peculiar character of pulse which we 
have observed in many examples of the debilitated heart in fever 
treated by free stimulation, the pulse having been restored to its natu- 
ral rate, and convalscence all but established. It continued to fall 
even as low as 32 in the minute, when it rose progressively to its 
natural standard. 

Thus in this case the pulse was — 

17th day 60 

18th " 50 

22d " 32 

25th " 60 

The convalescence was perfect on the 18th day. 

This case was a model example of typhus, in which recovery was 
not interfered with by any secondary lesion. The falling of the 
pulse so far below the natural standard is not constant, but I have 
always looked on it as showing that the heart had been greatly weak- 
ened, with or without muscular softening. 

I have told you that no rule can be laid down as to the actual 
quantity of stimulants to be exhibited. Every case has its own pe- 
culiarities even in the same epidemic. You will have differences in 
the necessity for stimulation, differences in the degree of vital pros- 
tration, in local complication, and in all the physical signs of the 
heart as to their nature, combination, mode of subsidence, and be- 
haviour under treatment. As a general rule the freer the case is 
from manifest local complication, apart from the vital depression of the 



ILLUSTRATIVE CASES. 205 

heart, the bolder may you be in stimulation. But you are not to 
allow the local complications — except that of active irritation of the 
brain — to deter you ; and even in certain cerebral cases, where cir- 
cumstances call for it, you may use stimulants tentatively. 

Two cases of most malignant typhus occurred to me some years 
ago. Both the patients were medical men; one was a young man of 
a non-excitable and phlegmatic temperament. In this case the use 
of stimulants was commenced at about the eighth day, and ran on 
for more than a week. The symptoms were extreme prostration, con- 
tinued — though not profound — coma, weakness of circulation, cold- 
ness of breath, enormous vibices, a general purpling of the skin, and 
paralysis of the bladder. A worse case so far as the essential disease 
was concerned could hardly be conceived. Fortunately the power of 
swallowing was unaffected, and you are not to despair of any case of 
fever as long as deglutition remains. During ten days the stimulants 
given were so varied and in such large quantity that his friends 
refused to continue them, thinking it would be a dreadful thing that 
the patient should leave the world in a state of intoxication. We 
could not persuade them that we knew better, and we had to send 
one of the class of this hospital to mount guard over the case, and to 
administer the wine and brandy perforce. By the twenty-first day. 
when the disease subsided, he had taken at least two dozen of wine, 
including port, Madeira, and champagne, with six large bottles of 
brandy. The recovery was perfect and without any accident, and the 
gentleman has since enjoyed many years of the best health. 

In the second case I did not see the patient until the twelfth day. 
He was a man of high mental culture and activity of mind and body. 
He had been attended by a physician of the anatomical and antiphlo- 
gistic school. In place of food he had got mercury, and in place of 
wine, tartar emetic. A glass of claret had been permitted on the day 
before we saw him. There was no disturbance of the brain, but he 
was covered with a petechial eruption approaching to purpura. The 
surface was cold, and the pulse almost imperceptible. From the mid- 
dle of the calf of each leg downwards, and over both feet, the surface 
was black, the skin hanging in loose wrinkles, giving an appearance 
as if the patient had on a pair of black socks. We expected mortifi- 
cation of the legs and feet, but, within twenty-four hours from the 
commencement of the stimulating treatment, the circulation was fully 
re-established, the blackness had disappeared, the feet had become 
warm, and the fulness of the limbs had returned. I need not tell you 
that stimulants were used boldly. In the first eight hours sixteen 



206 LECTURES ON FEVER. 

ounces of brandy were given. The patient made an excellent re- 
covery, and is still in the best health. 

In both these cases the patients had been of very temperate habits. 
The disease was a most severe but uncomplicated typhus, the nervous 
system not excited, and the stimulants agreed throughout. Both 
cases were thus well adapted for the bold and continued use of the 
stimulant treatment. 

Gentlemen, there is at present in our wards a patient whose case I 
would commend to your most attentive study. I refer to the young 
man Hardcastle, in whom the general symptoms of fever are presented 
in their most aggravated and appalling form. This patient is a native 
of England, and had been but a short time in Dublin. His case is 
full of instruction. 

I have mentioned that he is not a native of Ireland because it is 
probable that this circumstance has acted in modifying the symptoms 
of his disease. Had this patient been attacked with fever in his 
native place, he probably would have shown the symptoms of ordi- 
nary typhoid fever, and the case would have been a comparatively 
mild one. But at all events, this much we may believe, that different 
countries present endemic, sporadic, and even epidemic fevers, with 
characters in some degree peculiar to themselves; and we are not yet 
able to explain why fever in one country differs so much from fever 
in another — why maculated typhus should be so common in Ireland, 
and comparatively rare in England — or why the fever in Paris should 
so commonly present a particular local lesion. Many causes doubt 
less act; and I suppose among others, such as climate, diet, soil, and 
so on, the race and temperament are to be reckoned. 

I have suggested that if various families of mankind have a physio- 
logical stamp, they probably have also their pathological peculiarities. 
However this may be, it becomes a curious subject of inquiry, to de- 
termine what are the modifications of the symptoms of the fever in 
Ireland or in any other country, when the patient is not a native of 
the country, and especially if he has not been long resident in it. The 
most extraordinary case I ever witnessed was that of a gentleman, a 
native of France, who, after a long exposure to contagion during the 
famine fever, contracted maculated typhus here. He was a man of a 
sanguineo-nervous temperament, and exhibited during his illness a 
succession of symptoms widely different from those which we com- 
monly see in the spotted typhus of this country. He was profusely 
maculated, and the peculiarity of the case consisted in the irregular 
manifestations of various local symptoms — principally engaging the 
nervous system— and the inconstancy of the general condition, espe- 



RACE AND TEMPERAMENT. 207 

cially with, reference to excitement or collapse. This gentleman 
happily recovered, after passing through a storm of disease such as I 
and his other attendant, Dr. O'Ferral. had never seen before. 

Hardcastle is a young man who has been well educated, and he is 
evidently above the rank of the ordinary hospital patient. His symp- 
toms have been, from an early period of the disease, alarming in the 
highest degree. You will seldom see a worse case of adynamic fever. 
We may safely say, that for the last fortnight, both by day and by 
night, there has been an uninterrupted struggle between medical art 
and the fell disease which is upon him. During that time he has been 
lying more like a decomposing corpse than a living man ; but he has 
been kept from dying by the bold and constant exhibition of stimu- 
lants, by tonics, and by food. 

Some of you may wonder why it is that we thus go on with the 
increasing exhibition of stimulants — the untiring efforts to support 
life — although for the last ten days, at least, we have been hourly ex- 
pecting his death. The answer is, that we believe his disease to be 
one which may subside, sooner or later, under the law of periodic 
action. His recovery will then take place — not in consequence of 
the action of any specific which has the power of curing fever, but 
from causes the nature of which is hidden from us. We are like the 
defenders of a post attacked by a powerful enemy, but yet expecting 
succour, and we seek to hold the place until that succour arrives. 

There are two points in this case worthy of notice. One is that 
the nervous system has been so little engaged. He has had occasion- 
ally a slight delirium, and latterly some agitation and slight subsultus 
tendinum ; but though he generally appears sunk in stupor, it is not 
true coma, but rather the stupor of exhaustion, for, when you rouse 
him, his intelligence appears to be good. Is this escape of the brain 
to be looked on as favourable, or the contrary? According to an old 
and well-founded opinion, all anomalous circumstances in fever are to 
be feared. You know the aphorism, "Pulsus, vullus, et urina bona: et 
eager morilur." This contains an important truth ; but, in typhus, the 
want of nervous symptoms is in general favourable; for of the symp- 
toms referrible to one of the three cavities, doubtless those indicating 
nervous lesion are the most formidable. 

The second [joint to which I wish to direct your attention is, that, 
although this patient presents the symptoms of typhus so decidedly, 
he cannot be said to have any rnaculas or petechia:. In fact, his skin 
has been unaffected; there has been none of the so-called exanthema- 
tous eruption of typhus; and, even at this advanced period, the 
existence of petechia? is so doubtful, that I would not say that lie has 



208 LECTURES ON FEVER. 

them. Yet, if ever a man had the typhus gravior, this man has it. 
His surface exhales the peculiar odour of typhus, strongly marked ; 
he is prostrated to the last degree ; he has been kept alive by the most 
powerful stimulation ; he has a feeble heart, and well-marked second- 
ary affections of the intestinal and bronchial surfaces; his mouth is 
full of sordes ; his tongue black, dry, and cracked ; his breath fetid. 
The stethoscope indicates a general and severe bronchial affection, 
and there is a wasting diarrhoea. 

I am not going to take up your time by a discussion as to the dis- 
tinctive characters of typhus and typhoid fever. But it would be, I 
think, difficult even to the advocates of the distinction, to declare in 
which class this case should be placed. In this instance, as in most 
others, the settlement of the question is of little value; for, whether 
the disease be typhus or typhoid fever, the treatment should be no other 
than that which we have so far carried out. I may say this much, 
however, that the presence or absence of an early eruption having 
some similarity to an exanthem, or, again, the presence of petechias, 
appears to be insufficient to justify our drawing a strong line of dis- 
tinction between these diseases. I would advise you to receive with 
more than caution the doctrine, that the early eruption in typhus is a 
true exanthem, and that its absence in any given case points out that 
the disease is not typhus, but typhoid fever. 

Again, it is stated that the non-maculated fevers are often protracted 
and dangerous ; so they are, but not so often as they are short and 
easily managed. And I have not seen that relief of organs in typhus, 
which some describe as the rule, when the eruption appears. How, 
then, are we to look on the eruption. Certainly not as a distinctive 
mark between two different diseases. Gentlemen, we know that 
typhus fever will run its course and destroy life, without the necessary 
production of any hitherto ascertained anatomical change. We know 
further, that in many cases local alterations are formed, but that there 
is the greatest inconstancy in different epidemics, and in different 
patients during the same epidemic, in the seat, amount, time of appear- 
ance, and results of these local changes. The cutaneous rash is 
plainly one of this group of secondary affections ; and its absence or 
presence can no more be said to distinguish the disease, than the 
absence or presence of any other of these affections. I think we may 
admit that an early and florid eruption is often met with in typhus, 
which is well marked in other respects also; and again, that such 
cases generally require and bear stimulation. 

To return to the case of Hardcastle. We observe that there has 
been as yet no tendency to the critical or periodical retrocession either 



BED-SORES. 209 

of the secondary diseases or of the general affection. The fourteenth 
day passed by without any crisis, or without any subsidence of the 
disease ; the eighteenth day passed by ; the twenty-first day has 
passed by; and he is now in the twenty -fourth day of this terrible 
disease, kept alive by the use of wine, administered every hour, and 
also by the free use of hot brandy punch. He presents an appearance 
to-day to which I wish specially to direct your attention. You may 
remember that Saturday last was the twenty-first day, and it was 
then reported to me that the patient was getting a bed-sore. Upon 
examining him, we found in the ordinary situation of bed-sores a 
blush of redness and a slight degree of oedema ; but beyond that there 
was nothing remarkable. There was this point, however, which I 
observed at the time, although it was not until to-day that I thought 
it of importance, namely, that there was already a solution of continuity 
of the skin. Now, this is remarkable, and if such a case should occur 
to me again it would awaken my attention. In the ordinary cases of 
bed-sores we seldom see a solution of continuity of the skin at an 
early period; we see lividity, blackness if you will; but a solution of 
continuity of the skin before the ordinary appearances of mortification 
have occurred, is extremely rare. 

In this patient, on Saturday, just at the very centre of the livid 
patch on the skin, there was a slight solution of continuity. During 
the evening the nurse observed that several dark-coloured vesicles or 
pustules were making their appearance on various parts of his body. 
Mr. Parr saw these on Sunday, and he found that between the shoulders 
there was an eruption of livid tumours, which appeared to be some- 
thing between vesicles and pustules. To-day (Tuesday) such of you 
as saw the patient will not soon forget the extraordinary appearance 
of his back. I have been attending on fever in this hospital since 
1827, and I never saw anything of this kind before. 

Now, it is a very remarkable circumstance, that this eruption of 
gangrenous vesicles or pustules should have occurred upon the twen- 
ty-first day; and this case, as far as it goes, appears to strengthen an 
opinion, which I have long held — that we were in error in attributing 
what are termed bed-sores in fever, simply to mechanical causes. The 
general idea is, you know, that they are simply the result of pressure 
long continued on a particular part of the body, from the neglect of 
turning the patient in bed — of pressure combined with the effects of 
position. Now there can be no doubt that these are predisposing 
causes, but whether they are the sole and entire causes is another 
matter ; and I am almost convinced that the bed-sore in fever is often 
one of the group of secondary affections analogous to the ulceration, 
14 



210 LECTURES ON FEVER. 

or the tumefaction and ulceration, of the glands of the intestine — or 
to the bronchial affection which occurs in the middle stages of the 
disease — or to the other secondary organic diseases of fever. And if 
analogous to them, it should be more or less observed to be under the 
law of periodicity; it should appear and disappear at a certain time, 
or, at least, exhibit a tendency to do so. We have observed this very 
curious fact. There are cases in which the system seems to be in such 
a state that bed-sores will form from the slightest possible causes — 
that is to say, whenever there is any irritation or pressure, no matter 
how slight, a bed-sore will form in any part of the body. Some years 
ago we had a patient in this hospital, who, after the twelfth day, 
showed this tendency. She had bed-sores on the nates, and one on 
each shoulder. Then the tendency to the multiplication of these sores 
increased, and every morning two or three new ones were discovered. 
Wherever there was the slightest possible pressure, we found a gan- 
grenous spot — in the fold of the arm ; in the fold of the pectoral 
muscle; where the mamma leant upon the arm ; where the head leant 
upon the hand in sleep; where one leg lay on the other — the mark of 
a black hand was stamped upon the surface. In every possible posi- 
tion in which anything like pressure was made, or irritation excited, 
there were bed-sores ; and this tendency went on day after day, up 
to a certain day, until there were about thirty sloughs in different 
parts of the body. From that day — I might say from an hour of that 
day — no more bed-sores formed, although the constitutional symp- 
toms had not subsided. The patient then had to go through the 
process of throwing off all these sloughs, of granulation of the cavities 
from below, and of their cicatrization. She was kept lying on her 
face for upwards of a month, and finally recovered. 

Now what I want to draw your attention to in the case of Hardcastle 
is, that this extraordinary eruption of gangrenous patches on his back 
is not of the nature of bed-sores in the ordinary sense of the word. 
These patches are not produced by pressure. We find them in great 
abundance in the hollow of the back, where pressure is relieved by 
the pelvis and by the shoulders. We find them in abundance in the 
interscapular region ; but if we wanted additional proof it is this — 
that we find them on the anterior portion of the thorax. They came 
out as vesicles. These vesicles became hard at the top, then black, 
and soon the mass dropped out ; and this patient's back is now as if 
you took a sharp gouge and punched out circular portions of the flesh 
in a vast number of spots. Now it can hardly be doubted that this 
singular appearance is an example of a secondary disease affecting 
the surface ; and it is very remarkable that it should have appeared 



NATURE OF BED-SORES IN FEVER. 211 

on one of the critical days — upon the day when, in the ordinary 
course of fever, the disease should have subsided. It strengthens 
greatly the opinion, that not only is the general disease under the 
law of periodicity, but that the secondary alterations are so too. 

As a general rule, gentlemen, in prognosis, the occurrence of any 
vesicular eruption whatsoever in fever is bad. We have in fever 
several forms of vesicular eruptions. But suppose you take a patient's 
hand to feel his pulse, on the eighth or tenth day of fever, when he is 
otherwise going on well, and you are surprised at seeing a vesicle 
upon his arm. Do not neglect this-— do not overlook it. The mere 
circumstance of that solitary vesicle forming so silently, without any 
pain, without any notice, points out that there is mischief before you 
— that the case is likely to go wrong. It is a very important prog- 
nostic. Here we have on this patient an eruption of vesicles running 
rapidly to deep gangrenous destruction of the part, for some of the 
cavities formed by them are singularly deep, though circumscribed. 

Now, suppose that in place of that disease attacking the skin, upon 
the fourteenth day, or whatever day you please, it should attack the 
intestine. Suppose that the typhous matter suddenly infiltrated a 
gland in the intestine, which should fall as suddenly to gangrene, and 
that there was a solution of continuity ; you will at once see the pro- 
gress of the worst form of the typhous secondary disease of the 
intestine. You may look on this man as at this moment turned 
inside out. On the surface of his skin you are able to learn the 
history of the worst form of the typhous ulceration of the intestine. 
This extraordinary condition of his surface no one will say is inflam- 
mation of his skin. Apply the same view, and will you say that the 
disease of the intestine is inflammation of that part ? Certainly not. 

Whether this man is to live, gentlemen, or to die, I believe none 
of us can venture to say. Of course the chances are enormously 
against him; but I have said that in the treatment of fever you are 
never to despair so long as the patient can swallow. So long as he 
is able to take nourishment, or to swallow wine, no matter how dread- 
ful or apparently hopeless the symptoms may be, you are not to 
desert him, but — to use the phrase of our glorious sailors — you are 
to fight the ship while she swims. In a disease under the mysterious 
law of periodicity, every hour of compelled life is a clear gain. And, 
over and over again, you will find that your efforts will be crowned 
with success. You will see a patient lying with his back icy cold; 
you will see him pulseless — his lungs filled with secretion — his belly 
tympanitic — with dreadful diarrhoea — the lower extremities gangre- 
nous — himself in a state of insensibility — and yet, even under these 



212 LECTUKES ON FEVER. 

circumstances, a recovery is possible. But that recovery can be 
effected only by the steadfast determination of the physician not to 
desert his post until the vital spark has actually fled; and, if you 
commit an error in holding on — in hoping against hope — at all events 
it is an error on the right side. 



LECTURE XXIX. 

Stimulants in Fever, continued — Case of Hardcastle, continued — Treatment by food 
and stimulants in extreme cases — Presence of cerebral symptoms to a great extent 
unfavourable to tbe exhibition of stimulants — Necessity for daily observation of the 
effects of the treatment in each case — Signs of disagreement of stimulants — Routine 
practice is in every instance to be deprecated — Fallacies of the numerical system 
in therapeutics — History of routinism — Its results — Description of routinism in the 
treatment of fever. 

With reference to the case of Hardcastle, with which we were occu- 
pied at our last lecture, we may hope that the symptoms have at last 
yielded. The great interest of this case consists in its having been 
an example of a fever in which the patient was scarcely maculated, 
yet in which the stimulating treatment had to be pursued with an 
activity as great or greater than that which we are called on to employ 
in the worst cases of spotted typhus. 

On looking over my notes I find that on his admission, which was 
on or about the seventh day, he had a few scattered maculae on the 
abdomen, of a large size, and of a leaden gray colour. He then had 
diarrhoea, abdominal tenderness, and ileo-caecal gurgling; and the 
sounds of the heart, though weak, preserved their natural mutual 
relations as to force and duration. Doubtless the patient at this 
period might have been well described as labouring under typhoid 
and not typhus fever, according to the distinctions now in vogue ; 
but on the 14th, or the 21st, or the 24th day, he would be a bold 
man who would declare that the case was not typhus of the worst 
description. 

He is now at the 28th or 30th day of his illness, and we have 
every reason to believe that all will now go well. Since the eruption 
of gangrenous vesicles or pustules, which occurred on the 21st day, 
there have been no new appearances of this form of disease, there has 
been no new bed-sore, nor have the gangrenous patches spread, as 
might have been expected ; two of them are in the form of sinuous 
cavities, but even these show signs of healing. 



MANAGEMENT OF BED-SORES. 213 

These sores were treated first, you will remember, by the simple, 
and afterwards by the fermenting, poultice ; but as the latter gave 
considerable pain, the nurse returned to the simple poulticing, and 
now we have changed our plan, and are using stimulating dressings 
to the ulcerated surfaces. 

In the management of these sores, whether they be the ordinary 
bed-sores or examples of the gangrenous pustules, both of which 
appear to be of the nature of the secondary affections of typhus under 
the law of periodicity, it sometimes happens that we have to deal with 
extensive sinuses. I have seen them at times of not less than six 
inches in length. In most cases the best treatment for them will be 
stimulating injections, using the vulcanized India-rubber bottle with 
a long and slender ivory pipe. It is generally requisite at first to 
wash out the sinus with tepid water, and afterwards to inject some of 
the metallic solutions — diluted solutions of sulphate of copper, nitrate 
of silver, or sulphate of zinc — and when the discharge is very fetid, 
you may use the decoction of bark, or solutions of chloride of lime or 
soda. An excellent dressing when the sore is open is the Canada 
balsam combined with oil, or a mixture of equal parts of castor oil 
and balsam of copaiba. You will derive advantage, also, from the 
employment of pressure by means of flat compresses of lint, and a 
roller when it is possible to apply it, or in other cases you may 
employ strapping with adhesive plaster. When the sinus is in a 
depending position, and matter accumulates in its lower portions, it 
is sometimes necessary to make a counter opening; but this operation 
should rather be delayed until the system has improved; the case is 
then to be treated as an ordinary surgical one. 

Now let me draw your attention to the diligence with which the 
administration of wine has been pursued in this case. We began its 
exhibition on the 2d of November, which was the eighth day of the 
disease ; on that and the next four days, the quantity administered 
was six ounces daily. The wine used all through was port, of an 
excellent quality. From the 6th to the 11th he had twelve ounces 
daily, and from the 11th to the 18th his daily allowance was twenty- 
four ounces. During the next three days it was reduced to eighteen 
ounces; and from the 21st to the 25th, to twelve ounces per diem. 
On the 26th and succeeding days he had ten ounces; on the 28th the 
quantity was reduced to eight; on the 4th of December he had but 
four ounces; and the wine was omitted altogether on the 5th. Be- 
sides all this, a tumbler of hot brandy-punch, containing two ounces 
of the best brandy, was administered whenever the patient's state 
seemed to require it. In this way we used about twenty-four ounces 



214 LECTURES ON FEVER. 

of brand j, seven bottles of porter, and 432 ounces of wine, while, in 
addition, bark, musk, and ammonia were freely exhibited. 

Some may suppose that this quantity of wine was excessive. Such 
is not my opinion, nor will it be yours when you come to treat the 
typhus of this country in a large hospital. I am sure we might have 
given him with safety much more, and I doubt if we could have done 
with less. The result of the case confirms what I have said to you 
before, that in fever, no matter how terrible the group of symptoms 
may be, you are not to despair so long as the patient can swallow. Bear 
in mind, too, that Hardcastle has been carefully fed throughout with 
chicken broth, beef-tea, and jelly ; and we have now passed that period 
when, under the law of periodicity, his terrible disease should sub- 
side. 

The principal symptoms were extraordinary prostration, coldness 
of the surface, and feebleness and irregularity of the heart's action ; 
and it was not until the end of the eighth day of the exhibition of 
stimulants in great quantities that any favourable influence was pro- 
duced on the circulation. The case strongly illustrates the advantage 
of persisting in the use of stimulants, although for days together no 
amendment seems to follow their employment. 

I cannot too strongly impress upon you that even under appa- 
rently desperate circumstances life may be saved by the repeated 
introduction of small quantities of food and stimulants. Here we 
see the advantage of skilled nurse-tending. In the practice of a 
friend of mine a case occurred in which the power of deglutition was 
all but lost, the vital powers were sunken to an extreme degree, the 
action of the heart almost imperceptible, the eyes staring, with con- 
tracted pupils; while the symptom of lachrymation, regarded by 
experienced men as one of the worst in fever, was present. It was 
thought by all except the physician that the patient should be left to 
die. He, however, did not utterly despair. A large blister was 
applied to the occiput and nape of the neck, and a teaspoonful of 
brandy and beef-tea was administered every ten minutes during many 
hours. A slight motion of the eyelids was at last perceived. This 
was followed by deglutition, and after some time reaction had taken 
place. 

Some would say that in this most severe case the recovery was 
to be attributed to the blistering. It is more probable that it was 
connected with the action of the periodic laws, favoured by the 
continued introduction of stimulants. In such a case the use of 
enemata of beef-tea or of milk, containing in addition a small quan- 



INFLUENCE OF PREVIOUS HABITS. 215 

tity of brandy, aud also quinine, as recommended by Dr. Graves, is 
indicated. 

As to the employment of wine in a case seen for the first time, 
you will remember that in fever those who have been previously of 
temperate habits are generally the best subjects for the stimulating 
treatment. In our wards great quantities of wine have produced the 
best effects in the peasant class. Such men are by no means habitually 
intemperate. They may exceed now and then on the occasion of a fair 
or a wake, but their habitual drinks are milk, water, or tea. It is not 
so with the artisan class, who indulge in ardent spirits. Here I beg 
of you to remember what we have seen as to the anticipative treat- 
ment, and also that having to deal with a case of fever — say, in its 
first week — you cannot predicate how long it will continue. This is 
particularly true in the typhoid form, especially when affecting the 
adult. 

It would seem as if the frequent habit of alcoholic stimulation in 
health rendered the brain less capable of supporting wine under the 
condition of fever. At all events, you have seen that the use of 
stimulants where the patient had been a drunkard has by no means 
the same admirable result observed in men of a different habit. 

The freedom from symptoms of cerebral excitement, particularly 
when attended by heat of the head and increased action of the 
cerebral arteries, is of course favourable to the use of wine. 

But there is another cerebral condition which renders the use of 
wine in fever less often advantageous. It is met with in those whose 
occupation has long entailed a close and intense mental labour. Such 
subjects you will meet more frequently in the middle classes of 
society than among hospital patients, and in them we find that, while 
other circumstances indicate the free use of stimulants, their tran- 
quillizing effect is not seen, and they have to be omitted or used 
only at intervals. This is one out of many reasons why the over- 
worked professional man, especially if he be a physician, is so bad a 
subject for fever. Indeed, whenever you are called to treat a medical 
brother in typhus or in typhoid, you may lay your account at having 
a rock ahead. 

In the course of a case of typhus or the more prolonged examples 
of severe typhoid, in which you are giving wine, you must every day 
be on the look-out for symptoms that the stimulant is no Longer 
necessary or is disagreeing. Such a change is coin non, showing that 
the period has arrived when the stimulant is beginning to have the 
intoxicating effect which it would have were the patient not in fever. 
It is not easy to describe accurately this state, and you must learn it 



216 LECTURES ON FEVER. 

by observation. There is an undefined general excitement, some- 
times with heaviness and even a degree of delirium, often of a novel 
kind, together with loss of sleep. Symptoms not unlike many of 
those in the earlier stages of the case appear, while the pulse is more 
resisting and the patient complains of thirst and general malaise. 
Now, some of you have seen this group of symptoms in the advanced 
stages of fever where stimulants had been employed at first with 
great advantage, and you will remember the benefit which followed 
their disuse or diminution. This is a most important point of 
practice. Coincident with the use of wine or other stimulants you 
may have observed a gradual subsidence of the symptoms of fever, 
the re establishment of the heart's action, the coming down of the 
pulse, the cleaning of the tongue, and an improvement in the nervous 
symptoms. Under these circumstances the wine may be diminished 
gradually. 

But where there are indications that it is beginning to disagree, and 
that, in place of having a calming, it has a disturbing, effect on the 
brain and heart, although at first the opposite state had been induced — 
then the omission of the stimulant may take place at once, and the 
p.irient be supported on bland and unstimulating nourishment. You 
must have seen examples in our wards of the happy effects which 
followed the disuse of stimulants. 

When, in a protracted fever in which stimulants had been clearly 
indicated and had manifestly agreed in full quantity, symptoms of a 
more general disturbance of the system supervene, you must consider 
whether this condition is owing to an exacerbation of the essential 
disease or to the influence of stimulants ; in other words, whether the 
time has not arrived when their sanative action has given place to an 
opposite effect. Under such circumstances your course may be often, 
and safely, a tentative one. Such a course is recommended by Dr. 
Murchison when there is a question as to the giving of stimulants in 
the early stages of fever ; and here likewise you may feel your way 
in an opposite direction and watch the effect of a certain diminution 
of the remedy. 

Now, gentlemen, before concluding this lecture, I wish to say to 
the junior members of the class, and indeed to you all, that physicians 
are to be met with who boast that they do not give stimulants in 
fever, while, on the other hand, there are men in whose practice their 
use is a matter of routine. In either of these categories you may 
meet those who refer to and compare the numerical results of their 
practice. But these men have not learned how inconsequential are 
such comparisons. They have not learned how fallacious the results of 



KOUTINISM TO BE AVOIDED. 217 

the numerical system are in indicating a line of practice to be adopted 
in all cases. They have not perceived that life may be saved or lost 
by the adoption of this or that system— the advocates of stimulation 
saving those cases which required it, and their opponents those where 
it was injurious or unnecessary. 

It is true that the observations of the numerical school have been 
directed to determine what treatment in a certain disease will be 
followed with success in the greatest out of a given number. But this 
is not what the practical physician wants to know. Is it not rather 
what is best for him to do in the case of A, B, or C ? A certain 
treatment may have been successful in 75 per cent, of a group of 
cases, but he knows that this will not justify him in adopting it ex- 
clusively in all or in any of the remaining 25 per cent. 

He has learned that fever, in the general acceptation of the term, 
is a condition with laws of periodicity, and that, therefore, all thera- 
peutic conclusions as regards it will have to be estimated by a 
reference to this characteristic ; and, lastly, that fever is a varying 
condition, its cases — although capable of being arranged into groups 
— having certain similarities, but also infinite varieties, in local and 
essential symptoms; in amount, period, and degree of complications ; 
in the influence of remedies and in the epidemic character. Therefore 
in its treatment, and with reference to therapeutics, each case must be 
considered by itself. 

It is plain that dependence on the numerical system will encourage 
routinism — a line of conduct so opposed to the proper dealing with 
disease; for to adopt a practice deduced from the results of com- 
parison of numbers is but to justify routinism under the show of 
authority. 

It is hardly necessary to observe to the senior members of this 
class that the use of wine and other stimulants in our wards is in no 
way a practice of routine. Gentlemen, you have seen many cases 
during the last year in which wine was sparingly or not at all used 
in the course of the fever, simply because it was not required. Food 
was regularly given, while careful watching was practised, so as to 
detect early any sign of failure of the energy of the brain or circu- 
lation. 

It will be well to look at the various illustrations of routinism in 
the treatment of fever which we have known in this country. The 
Irish physicians of the last century might be called routinists in one 
respect — namely, that they employed wine and tonics in most cases 
liberally, if not indiscriminately. Like the old English physicians, 
however, they were eclectics, and so did not fall into many of the 



2^3 LECTURES ON FEVER. 

errors of their successors. Their doctrine of putrescence merely im- 
plied prostration of the system— in other words, debility was the 
condition to be guarded against and met; and doubtless, in the whole 
class of adynamic and essential diseases, if they erred, the error in 
practice was one on the right side. Drs. Quin, Plunket, and Harvey, 
all used wine freely in maculated typhus. Indeed, a bottle of Ma- 
deira daily was commonly ordered by them. To a certain extent 
they used it anticipatively, for they did not wait for the advent of 
extreme prostration. 

The next phase of routinism was of a different and opposite nature. 
The doctrines of Broussais, which taught that the essential disease was 
symptomatic of local inflammation, while the reverse was true, turned 
the minds of men into a wrong direction. The idea of inflammation 
was opposed to the exhibition of stimulants and tonics, and the 
practice of medicine was reduced to using direct or indirect de- 
pletion. 

The theories of Clutterbuck and of Armstrong supplemented those 
of Broussais as to inflammatory action being the cause of fevers, and 
so that new routinism in practice was generated, of which the leading 
characters were starvation and evacuation. The laws of periodicity 
in fevers were ignored, as was also the great fact in medicine that 
symptoms diagnostic of local disease when the patient has not essen- 
tial fever cease to be so when he has. 

Thus was established the routine practice of the adoption of eva- 
cuants, of bleeding, of diaphoresis, and even of purgatives. The 
system was pertinaciously reduced through every outlet, while little 
or nothing was introduced to supply the deficiency. The disciples 
of Broussais by applying leeches to the abdomen and by starvation 
reduced the patient to a state of inanition. Those of Clutterbuck 
did the same by depletion of the head for imagined cerebritis, and 
those of Armstrong operated similarly for the reduction of a supposed 
inflammatory diathesis. The depleting effect of acute disease, the re- 
duction of the volume of blood by the fever itself, the waste of tissue 
—were overlooked, while every new interference with the powers of 
nature more and more impaired the vis medicatnx. 

We may attribute to the same cause that timidity in the use of 
wine in fever whicli is still observable in the practice of some of our 
brethren, especially those who during their student lives have not 
been brought into daily bedside contact with the disease. I re- 
member some few years ago receiving an urgent call to see a 
lady in fever. I was entreated to lose no time in going, as the patient 
was so low, so far gone, that she had actually been ordered wine ! I 



HISTORY OF ROUTINISM. 219 

found the lady at about the fourteenth day of a low enteric or typhoid 
fever. She was extremely weak, and suffering under great mental 
depression and physical exhaustion, which had been present from 
the commencement of the attack. I recommended the immediate 
use of wine. "Oh," was the answer, "she has been ordered wine, 
and is now taking it." On inquiry it turned out that what had been 
ordered was light claret, the quantity being one or two teaspoonfuls 
in cold water twice or thrice a day. Now, this was the treatment of a 
physician whose opinion was in general not to be despised, but who 
had, like many of his contemporaries, been brought up not only in 
ignorance of the use of wine, but in a terror as to its effects on the 
supposed inflammatory condition of fever. My advice as to the 
quantity and quality of the wine was looked on as daring and inno- 
vating, but was nevertheless followed, and with full success. 

Closely following on the routine local and general antiphlogistic 
treatment in fever was a method which seemed to spring from the 
adoption of the views of Abernethy as to the influence of derange- 
ment of the chylopoietic viscera in introducing disease. A patient 
might or might not have a continued essential fever, but the intestinal 
and renal secretions showed derangement. Here the treatment 
recommended itself by its simplicity — a mercurial pill at night, 
followed in the morning by doses of infusion of senna, with rhubarb 
and gentian and Epsom salts, the care of the attendant being mainly 
directed to the appearance of the tongue and the inspection of 
the evacuations. This practice would be continued for days, the 
digestive organs obstinately refusing to right themselves, notwith- 
standing the treatment, until the patient began to sink, and was 
perhaps attacked with peritonitis, the result of perforation. Let me 
tell you a case of this kind. 

A gentleman previously healthy was attacked with symptoms of 
fever, and attended by two professional men long since dead, one a 
physician, the other a surgeon. He was treated for many days on 
the mercurial and purgative plan. I need not say that the fever 
continued, and as at last there was considerable sinking of the vital 
powers, a consultation was asked for by the patient's friends, and an 
eminent consulting physician of Dublin saw the case. He suggested 
that the treatment had been carried sufficiently far, and recommended 
chicken broth and a moderate use of wine. A light tonic, consisting 
of an infusion of cascarilla with a few drops of dilute muriatic acid, 
was also ordered. 

This was in the morning, and within two hours, the consulting 
physician having to leave town, I was hurriedly summoned to the 



220 LECTURES ON FEVER. 

case, it being alleged that the patient had been poisoned by the 
medicine. Violent pain had supervened just at the moment of swallow- 
ing the first dose of medicine. It was easy to see that perforation and 
peritonitis from long-continued intestinal disease had taken place. 
Nothing that I could say would induce the friends to take this view 
of the case, and to my surprise they were backed up by the medical 
attendants. I even drank some of the mixture in their presence. 
The patient sank in the course of some hours, and it was only by my 
declaring that a coroner's inquest should be held that I got permission 
to examine the body. The ileum was extensively ulcerated, and 
complete perforation had occurred in no less than four places. In 
one, probably that which caused the effusion into the peritoneum, 
the opening was the size of a fourpenny piece. 

The coincidence in time of swallowing the first dose and of the 
effusion into the peritoneum was singular. It was hardly down when 
the patient cried out, "I am poisoned! I am poisoned!" and re- 
mained in terrible pain until he was moribund. 

Here was a case of enteric or typhoid fever in which the intestinal 
disease was doubtless aggravated by the continued catharsis for many 
days. In the Report of the Meath Hospital, by Dr. Graves and 
myself, many cases of intestinal perforation are given where at thft 
commencement of the fever hypercatharsis had been induced by the 
exhibition of doses of saline purgatives. Looking at the routinism 
then prevalent, the case I have detailed was probably not an excep- 
tional one, and curiously illustrates that a knowledge of medicine is 
not necessarily implied in the legal qualification for practice. 

But as the principles of right reasoning in medicine are better 
inculcated and understood, and as larger views of the pathology of 
fever — such as those taught by John Peter Frank, by the fathers of 
British medicine, and by modern writers, like Christison, Graves, 
"Watson, Murchison, Jenner, and Tweedie — are more generally known 
and made use of in medical education, the older as well as the newer 
forms of routinism will disappear. The time is coming rapidly when 
routinism in its successive phases will be forgotten, and the state of 
fever be dealt with in a philosophical spirit. 

Before concluding this lecture let me give you an extract from one 
of the writings of a witty medical satirist, the late Dr. Brennan, of 
Dublin, commonly called " The Wrestling" and sometimes " The 
Turpentine Doctor." It is entitled "A Receipt to Make a Fever," 
and is a picture of the practice of the day three-quarters of a century 
ago — unhappily, not yet extinct: — 



A RECEIPT TO MAKE A FEVER. 221 

Any patient, when you get him, 
First of all, be sure you sweat him : 
The next day you need not heed him, 
But the third take care to bleed him. 
When he's sweated and he's bled, 
Then, of course, you'll shave his head ; 
Clap on five-and-twenty leeches, 
Tho' the first cost a crown each is. 

When to sink he does incline, 
Blister legs and give him wine. 
Tell his uncle or his brother 
That you'd like to see another — 

Yet let nobody approach 

But a doctor in a coach ; 

For a coach does mighty wonders 

In concealing doctors' blunders. 

The writer then passes in satirical review the different consulting 
physicians of Dublin, concluding with himself: — 

If they talk of Brennan's knowledge, 
Say, "He is not of the College," 
Or, to joke if you incline, 
Smiling mention — Turpentine — 
And you may throw in — by dad ! — 
That you know he's wrestling mad. 



The patient dies 



When with drugs you well have swilled him, 

Tell his friends the fever killed him ; 

All that could be done was done — 

The worst you ever saw, but one : 

And this is a mighty consolation 

In such an awful visitation. 



LECTURES ON FEVER. 



LECTURE XXX. 

Treatment of the Local Secondary Affections in Fever — Relative importance of 
these affections as regards prognosis — Bronchial Affections — Necessity for ad- 
ministration of stimulants and nourishment — Danger of exhibition of tartar emetic 
— Failure of emetics— Turpentiue-puncli — Dry-cupping, poulticing, blistering — 
Internal remedies: bark, ammonia, spirit of chloroform, turpentine — Acute Con- 
solidation of the Lung — Its three forms — Treatmeut of the first form by dry-cupping, 
blisters, quinine, turpentine, and wine — Of the second form by local depletion 
simultaneously with the administration of wine — Of the third form, externally by 
iodine and blisters, internally by tonics and iodide of potassium. 

Following the plan which 1 have laid down in this course of lec- 
tures, I shall to-day direct your attention to the management of the 
secondary local affections of fever. We may classify these under four 
headings, according as they involve the nervous, circulatory, pulmo- 
nary, or digestive systems. 

Were we to attempt to classify these local affections with respect 
to their importance as regards the parent disease and the safety of the 
patient, it would be difficult to determine whether the nervous, circu- 
latory, pulmonary, or digestive symptoms should be considered as 
entitled to the first place. 

In reference to prognosis, the predominance of cerebral symptoms 
may certainly be held to be of unfavourable import, and one reason 
for this is that their presence often interferes so materially with the 
attempt to combat prostration by the administration of stimulants. 
But, apart from this consideration, the preponderance of cerebral symp- 
toms is more serious as always indicating — not necessarily organic 
change in the nervous centres — but a functional disturbance in them 
which reacts on all the other systems of the body. 

If, however, we were to classify the various phenomena connected 
with the different systems of the body in fever according to the 
amount of their corresponding anatomical changes, we should say 
that the pulmonary affections are the most liable to changes of this 
description. 

Thus, notwithstanding all the researches which have been insti- 
tuted respecting the anatomical changes in typhus and typhoid fevers, 
no one can at present venture to say what condition of brain corre- 
sponds to this or to that symptom in these diseases ; no one can 
accurately determine the state of the brain as regards its anatomical 



CHARACTER OF CEREBRAL SYMPTOMS. 223 

changes from the observation and study of any symptom. We may 
recognize a condition of brain in fever in which stimulants will not 
be borne, and another wherein they are useful, but we may be unable 
to reduce either of these to an anatomical expression. As we have 
seen in a former lecture, there is no symptom in ordinary fever 
whereby we can determine the presence of actual and progressive 
cerebritis or arachnitis. One patient will be in a state of high delirium, 
with injected brain, another will have an injected brain in the absence 
of any such symptom. 

These are important facts, most necessary to be kept in mind ; but 
you are not to infer from this that we are altogether powerless in the 
treatment of the cerebral symptoms of fever. All that has been said 
shows only, that, in dealing with the special condition of existence to 
which we give the name "fever." our pathology must not be too 
material in its character or tendency, and that the symptoms of merely 
functional suffering are infinitely varied in nature, time of appearance, 
intensity, and their degree of combination with organic change. 

I have said that of all the secondary diseases of fever those affecting 
the pulmonary system are the most frequently attended by anatomical 
change, and among these — the bronchial affection — for primary 
bronchitis it does not seem to be — most especially so. 

It is remarkable how silently this affection will be developed in 
proportion to the severity of the fever. From superficial observation 
the presence of serious bronchial disease might never be suspected, 
but on exploring the chest morbid sounds may be heard universally 
in front and behind. Yet there may be no severe cough, no extreme 
dyspnoea, or lividity of countenance. 

Frequently with this secondary disease in malignant typhus an ex- 
treme degree of weakening of the heart, with softening of that organ, 
will be found associated. By having regard to this complication we 
obtain the key to the treatment which is especially indicated in these 
cases — namely, the free administration of stimulants and nourishment. 
Here, also, the anticipative method of treatment is often indicated, 
for the secondary bronchial affection with a weakened heart places 
the patient in a position— it may be — of the most imminent peril. The 
heart grows weaker, and there can be little doubt that its weakened 
condition is repeated in the muscular fibre of the lungs and bronchi. 
The bronchial tubes are loaded, mucus is copiously secreted, the 
muscles which assist the act of expectoration become paralyzed, and, 
should relief not be afforded, the almost inevitable result is asphyxia 
and death. 

These observations arc simply suggestive of the necessity of adopt- 



224 LECTURES ON FEVER. 

iDg a decided and active system of treatment. The more closely you 
investigate cases of this kind, the more convinced will you be that 
paralysis of the circular fibres of the expectorant muscles takes 
place; and here we have one — perhaps the principal — reason why 
the liberal administration of stimulants is found so successful under 
such circumstances. It may be that even after recovery from the 
primary disease death will ensue from purely mechanical obstruction 
in the lungs and air-passages. This is another reason for adopting 
the principle of meeting the disease early. I never saw a case of 
death from secondary bronchial effusion except where the disease had 
been overlooked at first. 

Now let us advert to the general mode of treatment of this com- 
plication. Suppose you are called in to a patient, say on the fourth 
or fifth day of typhus. You find a rale in the large bronchial tubes, 
extending next day into the smaller tubes. Will you call this " bron- 
chitis" and treat it as such? Certainly not. You have before you a 
patient in a certain condition as regards the respiratory functions, 
which condition is under the influence of the parent malady. If 
there be any inflammation present in such cases, it is specific, 
asthenic, and reactive, not to be treated by antiphlogistic means. 
The presence of the rale is not to induce you to bleed or to apply 
leeches, but what you have to trust to is active and energetic stimulant 
derivative treatment. Some physicians recommend in such cases 
the exhibition of tartar emetic. Where this course is followed the 
patient may sink. 

Now, the inveterate habit with which men in our own time were 
imbued, of attributing every local symptom in fever to inflammation, 
led to the practice of giving mercury in this condition. But you will 
easily see the unfitness of such a course when time is pressing and it 
is absolutely necessary to modify the vital, and relieve the mechanical, 
state of the lung which threatens asphyxia. My friend Dr. Mackin- 
tosh, of Edinburgh, strongly advocated the use of emetics in this 
condition ; but I do not recommend them — at least they have not been 
hitherto successful in our hands. You will meet cases in which they 
will not act at all. I have seen the most powerful emetics, of various 
kinds, exhibited without any vomiting whatever being produced. I 
have known cases in which, after milder remedies had been used, the 
sulphates of zinc and copper utterly failed. Or the full action of the 
emetic may occur, and be followed by great relief of the chest; yet in 
a short time the suffocative state will return, and, the sensibility of 
the stomach being destroyed, the patient sinks asphyxiated. 

But the course of treatment under these circumstances long 



TREATMENT OF BRONCHIAL AFFECTION. 225 

followed in our wards is dry cupping, blistering, and the free exhibi- 
tion of turpentine in whiskey-punch. By this course our late 
excellent apothecary, Mr. Parr, saved many a life when the patient 
was almost in articulo mortis. He would administer a tumbler of 
strong punch with two or three drachms of spirit of turpentine, and 
repeat the dose, if necessary, in a short time. Often has he said to 
me in the morning, "Sir, I had. to punch three cases last night — they 
are all doing well." The effects were simply wonderful, and illustrate 
the principle that you are not to despair in a case of fever so long as 
your patient can swallow. 

This reminds me of a translation by Dr. Brennan in the Milesian 
Magazine : — 

Si quid novisti reetius, istud candidus imperti. 
Si non, his utere mecuni. 

Doctors ! if you have better drugs than mine, 
Say where they're hid ; if not, use turpentine. 

In this theatre my late colleague, Dr. Graves, dwelt largely on the 
value of this medicine in the secondary affection of the lungs in 
fever, and he has been followed emphatically by Huss of Stockholm. 

In the less urgent cases you are not to forget that the disease may 
show a sudden and violent exacerbation ; and I have often heard 
practitioners account for the occurrence of tracheal rattle and fatal 
asphyxia and excuse themselves on the supposition of a sudden effu- 
sion into the chest, when, in truth, the bronchial tubes had for days 
been engaged, and the affection unrecognized and neglected. 

I repeat that in fever, especially in typhus, with a weakened heart, 
the affection of the bronchial tubes may be developed insidiously and 
to a great extent. 

With respect to external and local applications in ordinary cases 
of this secondary affection, I have already spoken of the use of 
dry- cupping. Amongst other means may be mentioned the repeated 
application of turpentine fomentations; of poultices consisting 
wholly of linseed meal, or of linseed meal and mustard in varying 
proportions; and of moderate-sized blisters, covered with a linseed 
poultice, so that the vesicating action shall be favoured by the 
warmth and moisture of the poultice. 

Of internal remedies, the decoction of bark, with ammonia and 
spirit of chloroform, is most frequently indicated : or moderate doses 
of turpentine may be employed with good effect. The confection of 
turpentine administered in peppermint water is found to be a valuable 
preparation. But above all it will be necessary to support our patient's 
15 



226 LECTURES ON FEVER. 

strength by the judicious administration of suitable nourishment, and 
wine or other stimulants. 

Acute consolidation of the lung in fever may be considered, 
with regard to practice, under several forms: First, that in which 
symptoms and signs of anything like acute or sthenic inflammation 
do not occur. The disease is in these cases more or less silent or 
latent, and recognizable chiefly by physical signs. You are to treat 
this affection by dry-cupping, blisters, quinine, turpentine, and wine. 

But between these cases and others where a greater activity of the 
ordinary inflammatory symptoms is observed, indicating that a local 
antiphlogistic treatment may be employed with advantage, there 
exists an intermediate form which includes cases of almost infinite 
shades and varieties of character. 

In cases of the secondary pneumonic affection which possess 
many of the characters of acute sthenic pneumonia, there may be 
pain in the side, great local increase of temperature, and distress of 
respiration. Here the application of a few leeches, or of the scarifi- 
cator and cupping-glass, may be followed by immediate and marked 
relief to the patient. In many such instances the use of wine is not 
to be intermitted on account of the practice of local depletion. There 
is a point of great importance in practical medicine — one which I 
wish to impress strongly upon you — namely, that lines of treatment 
apparently opposite or antagonistic may, under certain circumstances, 
be employed simultaneously with success. Your treatment is to be 
influenced not by the name of a disease, but by the condition of your 
patient; and you may relieve local irritation by local blood-letting 
while you support the general system, and deal with the essential 
disease by the use of stimulants. 

When describing in a former lecture those consolidations of the 
lung, especially of its upper lobe, in fever, which seemed to partake 
of the nature of a crisis, I said that it was often a matter of doubt 
whether the clearing of the lung was to be attributed to the remedial 
measures employed or to the spontaneous subsidence of the condition 
in obedience to the law of periodicity. However, a small blister or 
two may be used, and the application of the tincture of iodine ex- 
ternally, with the exhibition of iodide of potassium in combination 
with a tonic, may be of advantage. 

I need not say to the students of large bedside experience that it 
is sometimes difficult to distinguish between a primary pneumonia 
with a symptomatic fever and states of the lung secondary to typhus 
or to typhoid. You will, also, be prepared to hear that this difficulty 
has been more commonly met with since the period of change of type 



TREATMENT OF INTESTINAL SECONDARY AFFECTIONS. 227 

in disease. Still, during the last few years, several cases of primary 
pneumonia have come under our notice, in which, though with less of 
the general violence of symptoms once so familiar to us, we have 
used the lancet — moderately, it is true, but with the most rapid suc- 
cess. The pain, the adhesive red expectoration, the state of the heart, 
and the early appearance of the symptoms, were our chief guides. 

The dreadful occurrence of sphacelus in consolidation of the lung 
in typhus is to be met by the antiseptic and stimulant treatment. 

That recovery is possible in this catastrophe I have already shown 
you. The patient in question died after a lapse of some years from 
the first attack. We found recent sphacelus in one lung, and a 
cavity containing a dry slough, and with a firm lining membrane in 
the other. 



LECTURE XXXI. 

Treatment of Intestinal Secondary Affections. — Two chief indications : (1) allevia- 
tion of symptoms, (2) modification of typhous deposition — Poulticing — Local de- 
pletion in early stage — Analogy in variolous eruption — Danger of alterative or 
purgative treatment at the outset of Continued Fever — Necessity for caution — Con- 
stipation — Diarrhtza — Poultices, demulcents, sedative astringents, injections of flax- 
seed tea — Tympany — Turpentine injection — Diet in diarrhoea — Perforative peritonitis 
— Opium our sheet-anchor — Danger of the antiphlogistic method — Dr. Murchison 
on the treatment of this accident — Bran poultices and warm fomentations — Hemor- 
rhage from the intestine in fever — Not to be interfered with unless continued and 
excessive — Treatment by astringents, opium — Illustrative case. 

In a case of enteric fever, or of a well marked typhus with more or 
less of intestinal affection, your efforts in reference to the treatment 
of the local secondary disease will be directed less to the cure than to 
the palliation of the symptoms, and to diminishing the activity of that 
process under which the mucous membrane and glands become the 
seat of the typhous deposit. 

We seek to lessen the amount of change by modifying the specific 
and afterwards the reactive irritation. 

Local bleeding and diligent poulticing are the measures on which 
reliance is to be placed in the first instance, while everything which 
might excite overaction or hypersecretion of the intestines is to be 
avoided. The first of these remedial measures is best effected by- 
moderate leeching of the ileo-caecal, and in some cases the epigastric 
regions, due regard being paid to the strength of the patient and to 



228 LECTURES ON FEVER. 

the period of the case at which the local symptoms become manifest. 
In the earlier periods from six to ten leeches may be applied first to 
one and then to the other situation, and this will be often followed by 
the relief of local suffering and — as regards the general symptoms — 
by the best effects. The repetition of this local bleeding will depend 
on circumstances. But if tenderness, local fulness, increased arterial 
action of the belly, or muscular rigidity be wholly or in part removed 
or modified, it is not often necessary to repeat the application. I 
need scarcely say that the presence of these symptoms affords an in- 
dication for this early use of local depletion. 

I have shown you that Broussais, in defence of the doctrine that 
fever was only symptomatic of gastroenteritis, appealed to the fact of 
the relief which often follows local depletion, and I have suggested a 
more probable interpretation of the entire matter. Local depletion, if 
employed sufficiently early in the case, may prevent altogether, or 
greatly modify the development of intestinal symptoms. Here it 
would seem that the lessening of the blood supply interfered with the 
deposition of typhous material along the intestinal tract in the agmi- 
nated and solitary glands. This is strikingly analogous to what is 
observed in certain cases of variola, where the local development of 
the secondary eruption on the face or elsewhere is largety under 
control by the application of leeches or by strapping the part at an 
early stage of the disease. This point T have already illustrated in a 
former lecture. 

Again the analogy holds good with respect to the pustular eruption 
of variola, and the secondary typhous deposits of fever in the intesti- 
nal tract. For even where there is good reason for supposing that 
these deposits have already taken place, and are passing on to ulcera- 
tion, it is found that local depletion may be of the greatest use in 
allaying irritation and so preventing the violence of a reactive inflam- 
mation. 

All this goes to prove that the influence of local depletion cannot 
be taken as an evidence of the primary nature of the local malady ; 
for in the first place it receives a similar and easier explanation from 
the hypothesis of an essential disease with a secondary local affection ; 
and in the next place the argument from analogy is altogether in sup- 
port of this hypothesis, and against the views of Broussais. 

It is still necessary —I regret to say it — to warn you against follow- 
ing the routine practice of giving what is called " alterative," combined 
with purgative, medicine, in the early periods of fever — a' course too 
commonly followed, even while the practitioner is unaware of the 
nature of the disease he is treating. In this way a threefold injury 



CONSTIPATION AND DIARRHCEA. 229 

is inflicted. The strength of the patient is exhausted at a time when 
it should be husbanded ; the normal course of the fever is interfered 
with ; and, should there be any tendency to the intestinal affection, it 
is doubtless augmented and exasperated by measures which determine 
to the part of the economy most likely to be the seat of lesion. This 
is analogous to what is often observed in constitutional maladies. 
Thus, in cancerous cachexia the local organic change is frequently 
determined by the receipt of some injury. In acute essential diseases, 
again, the same thing is noticed, as for example in variola, where the 
application of rubefacients will be followed by an increased develop- 
ment of the eruption, while a contrary effect will, as we have seen in 
a former lecture, be produced by local depletive measures. 

In a large proportion of our cases of perforative peritonitis, hyper- 
catharsis by saline purgatives had been induced at an early period 
with the mistaken view of seeking to cut the fever short. 

We have spoken of the use of leeches and of light poulticing. 
Should there be constipation, with swelling of the abdomen, to such 
an extent as to render it advisable to free the bowels, mild enemata 
may be employed, and turpentine fomentations applied to the surface. 
The enemata must be composed of the blandest fluids, to which, if 
there be any troublesome tympany, a little turpentine made into an 
emulsion with yolk of egg may be added. 

I am ready to admit that cases will constantly present themselves, 
in which the practitioner will be at a loss to determine whether con- 
tinued fever is threatening, or the symptoms are to be referred merely 
to the presence of a " feverish cold." Under these circumstances I 
would still inculcate the necessity for caution, and would recommend 
that the smallest doses of aperient medicines likely to effect the ob- 
jects in view should be employed. 

But when you have symptoms of irritation of the intestine attended 
by diarrhoea, the use of poultices and of demulcents may be combined 
with that of astringents of a sedative nature. I know no better 
remedy than the acetate of lead given with some preparation of opium. 
In the form of pill these two drugs may be conveniently given ; but 
if ordered in a mixture, it will be necessary to substitute the acetate 
of morphia for crude opium. I have never seen any bad result from 
lessening or checking the diarrhoea, or any symptoms of lead-poison- 
ing, even when this medicine had been continued for many days. 

Here I may allude to the fact, that, in the first two epidemics of 
cholera in this city, the use of the " pilula plumbi cum opio" was intro- 
duced by Dr. Graves, following the recommendation as to the value 
of the acetate of lead in the diarrhoea of Continued Fever by Sir 



230 LECTUKES ON FEVER. 

James Bardsley. 1 The remedy, in the hands of Dr. Graves and of 
many others, was employed in a vast number of cases, and I believe 
that during this great clinical experiment not a single case of lead- 
poisoning occurred either in the earlier stages of the case or in the 
later period of convalescence. We must, of course, remember that the 
acetate of lead is by no means so poisonous as the carbonate ; but I 
would caution you against its possible change into this latter salt. If, 
for instance, it is compounded in a mixture with water containing 
carbonate of lime, it may be decomposed. This is still more likely 
to occur in the use of lead-lotions. The most violent and long- 
continued case of lead-colic I ever saw was that of a woman who had 
suffered from an extensive burn of the abdomen. Lead-lotion was 
applied to the injured surface for weeks together, and we must sup- 
pose that a considerable quantity of carbonate of lead was formed and 
absorbed, for symptoms of poisoning soon showed themselves. 

To return — you are to use demulcents either by the mouth or in 
the form of injection. I remember, when a student, that a remedy 
called the " mistura olei et opii," was extensively employed in this 
hospital, and with the best effect. It was an emulsion of oil, 
gum arabic, and cinnamon water, to which a little laudanum was 
added. We used to believe that it acted mainly in lubricating the 
irritated surfaces. The injection which we have employed with 
greatest advantage in diarrhoea in fever has been one of flaxseed tea, 
to which a few drops of laudanum may be added. The infusion of 
flaxseed should be made with unbruised seed, and its effect in pro- 
ducing a sensation of general soothing, perceived throughout the 
intestinal tract, is most remarkable. 

I have already spoken of the value of a turpentine injection in cases 
of constipation with tympany, but when this latter symptom accom- 
panies diarrhoea, and becomes very extreme, the same remedy is often 
indicated. You might suppose that given by the mouth the turpen- 
tine would act as a purgative ; but if it is given in small and repeated 
doses — as, for example, from 15 minims to half a drachm every two 
or three hours — the result may be just the opposite. 

Nor is the mere symptom of tympany to be neglected, for although 
it is by no means commonly of much importance in the early stages 
of intestinal lesion in fever, it may assume dangerous proportions. 

Some years ago a case occurred in these wards in which abdominal 
tympany seemed to be the direct cause of death. It resisted all 

1 Clinical Lectures on the Practice of Medicine, reprinted from the second edition, 
1864, p. 317. 



PERFORATIVE PERITONITIS. 231 

remedies, and we failed in the attempt to pass the long tube beyond 
the sigmoid flexure. On dissection the small intestine and the colon 
were found enormously distended — the large intestine being turned 
over and obstructed by the formation of a complete fold at the com- 
mencement of the sigmoid flexure. 

Two points connected with the treatment of diarrhoea in fever 
remain to be considered. In the first place, we have to deal with the 
question of diet. We have already spoken of diet generally in fever, 
and you will remember the rules which were laid down for your gui- 
dance. It is occasionally found that beef-tea tends to increase the 
diarrhoea. Should this occur, we must either give it in smaller quan- 
tities, or suspend, its administration. Chicken broth may be substi- 
tuted, or farinaceous foods employed. Arrowroot with port wine, sago, 
tapioca, rice, rice milk, plain or boiled milk, and milk and lime-water 
in varying proportions are articles of diet to which recourse may be 
had. I have also used eggs, and have found them to agree perfectly. 
They may be boiled, or beaten up raw with milk sweetened with 
sugar. " Egg-flip," or the " mistura spiritus vini Gallici" of the " British 
Pharmacopoeia," is one of the most valuable stimulant and nutritive 
preparations we possess. 

The second point relates to the exhibition of other astringents than 
those already mentioned. These are " chalk mixture," gallic and 
tannic acids, the astringent tinctures (kino, rhatany, logwood, and so 
on), and dilute sulphuric acid. They are, I believe, all useful in their 
\va} r . I have given pills of tannic acid combined with Dover's pow- 
der with good effect; but the most valuable of the remedies I have 
just named is undoubtedly the dilute sulphuric acid. It has a three- 
fold value — it allays thirst, acts as a tonic, and possesses powerfully 
astringent properties. It may be administered frequently, and in 
doses of from 15 to 25 or 30 minims well diluted ; or the aromatic 
sulphuric may be substituted. 

We shall now speak of peritonitis resulting from perforation of the 
intestine, the occurrence of which may be explained by that insuscep- 
tibility of the peritoneum to adhesive inflammation which we have 
already considered. Eemember how rarely we meet with general 
adhesions of the peritoneum in comparison with the frequency of such 
a condition in the pleura. Now, it would appear that the violent 
symptoms of perforation depend, less on a localized serous inflamma- 
tion corresponding to a perforating ulcer of the intestine, than on the 
fact that an effusion of the contents of the tube into the general cavity 
.causes suddenly an extreme and commonly fatal inflammation. You 
may occasionally meet cases where, although the serous membrane is 



232 LECTURES ON FEVER. 

perforated, no general inflammation occurs— the process is circum- 
scribed, and is not attended with any effect on the constitutional 
symptoms. In fact, there is occlusion of the opening — the base of the 
ulcer being formed by the serous membrane of the adjacent fold of 
intestine, so that no effusion of the contents takes place. And we 
have seen that the effect of intense irritation in another cavity may 
be to render latent even a general inflammation from effusion, as in 
gastro-catarrhal fever or in cases of cerebral complication. 

Dr. Murchison 1 gives a remarkable example of the latter. A young 
man aged 19, in enteric fever with acute delirium, suffered from pro- 
fuse intestinal hemorrhage, but there were no symptoms of peritonitis. 
After death, on the 19th day, there were found ulceration of the 
intestine, perforation, and peritonitis. 

Now, if we compare this terrible accident with the analogous con- 
dition of empyema and pneumothorax from perforation of the pleura, 
it seems to be more rapidly and certainly fatal. For, although in the 
chest the accident is often attended by violent symptoms, these are 
attributable rather to the frequently consequent and sudden collapse 
of the lung than to the influence of the resulting pleuritis on the 
nervous system. 

It frequently happens in pneumothorax, that, after the first storm 
of suffering is past, there comes an interval of calm — often prolonged 
— while occasionally many of the vital symptoms of pulmonary dis- 
ease disappear. The condition of collapse and compression seems, 
even for a long time, to suspend the diseased process in the lung, so 
that its constitutional symptoms may actually subside and disappear 
temporarily. 

It was long believed, and is by some still held, that general peri- 
tonitis from perforation in fever is invariably fatal. But we have in 
this hospital arrived at a different conclusion. It is now many years 
since a female suffering from ascites, and under the care of Dr. Graves, 
underwent the operation of paracentesis, soon after which she was 
seized with symptoms of acute peritonitis. In those days, I may tell 
you, such an accident in the operation of tapping was not uncommon, 
and no wonder. A very large trocar and canula were employed, and 
efforts made to get rid of every drop of fluid. With this view the 
abdomen, while the canula remained in the wound, was compressed 
and kneaded in various places — the mouth of the hard instrument 
thus scraping against the serous membrane of the intestines — and a 
tight bandage afterwards applied. Besides the effect of all this vio- 

1 Continued Fevers of Great Britain, second edition, page 571. 



OPIUM IN INTESTINAL PERFOEATION. 233 

lence, the serous surfaces, long separated from the effusion, were 
rapidly brought into contact, so that you can easily understand the 
frequency of peritonitis. The accident is now comparatively rare. 

In the case before us the strength was greatly reduced, and no 
remedial measure was proposed by the operator. The woman being 
in extreme pain, Dr. Graves administered a full opiate, with the best 
effect. Sleep soon followed, and after a few hours the patient awoke 
with the symptoms greatly alleviated. The opium was repeated in 
diminished doses, and after a few days all the symptoms of acute 
peritonitis had subsided. She made an excellent recovery. 

The success in this case determined us to employ opium in free 
doses in the first example of perforative peritonitis which occurred, 
and the practice has since then proved in many instances successful. 

The two great indications of relieving pain and of controlling the 
peristaltic action have been in these wards and in the practice of 
several of my friends fulfilled with the happiest effects, while the 
interesting result of the tolerance of opium in large quantities in 
acute peritonitis has been established. Thus a grain of opium, 
exhibited every hour, has been often given without any poisonous 
effect whatever. 

A case occurred here which illustrates the danger which may 
follow any excitement of the peristaltic action even after recovery 
from the first access of peritonitis has ensued. A young man, in an 
enteric fever, was suddenly seized with the most violent symptoms 
of peritonitis. The pulse became small, rapid, and wiry — the abdo- 
men swollen and exquisitely tender. No doubt was entertained as 
to the occurrence of a perforation, and the opium treatment was at 
once resorted to and continued for twenty-four hours. Next day the 
symptoms were greatly lessened in intensity, and we continued the 
remedy at longer intervals for a few days. All symptoms of perito- 
nitis disappeared, the abdomen felt natural, and the pulse had returned 
almost to its normal standard. The patient's condition improved 
daily, he took nourishment freely, when, the bowels having been 
confined for many days, a very mild saline laxative was unfortunately 
given. It acted gently, when the former symptoms at once returned, 
and the patient sank in the course of some hours. On dissection, 
well-formed but recent adhesions were found in different portions of 
the peritoneum — evidently the result of the first, all-but-cured attack. 
The perforation was in the ascending colon. It was patulous, while 
bilious and feculent fluid existed in the serous cavity. 

Now, that this patient would have been saved, had the laxative 



234 LECTURES ON FEVER. 

been withheld, there can be little doubt, and the case is full of instruc- 
tion and warning. 

There are few more interesting and important facts in therapeutics 
than the tolerance of opium in repeated doses in this form of perito- 
nitis, and the remedy has been found applicable in other cases besides 
those of intestinal perforation. It has succeeded in a rupture from 
an over-distended bladder, in which immediately after the accident 
no urine could be found by the catheter. In a case in which an he- 
patic abscess had opened into the peritoneum, the inflammatory symp- 
toms entirely subsided after a few days of the opium treatment. On 
dissection, after death from another abscess, numerous organized 
adhesions were observed between the convolutions of the intestine and 
the parietal peritoneum. 

In connection with this subject of the treatment of perforative peri- 
tonitis, it may be well to remind you that this complication of fever, 
like the other secondary affections, varies in frequency according to 
the prevailing epidemic characters of the disease. Thus previously 
to 1827 Dr. Graves observed but one instance of the lesion out of 
more than 1000 cases of fever, while during the session of 1828-29 
the occurrence was frequent in Dublin. At the present day, again, 
even though enteric fever has increased in prevalence, this terrible 
accident is comparatively rare. 

Dr. Graves and I 1 have shown that the antiphlogistic method of 
treatment is not so applicable in these cases as in examples of idio- 
pathic peritonitis. In the first place, the perforation occurs at an 
advanced period of some other disease, when the constitution is 
enfeebled, and, at the time you will be called on to interfere, the 
patient is suffering not merely from general peritonits but from the 
collapse which attends the accident. The disease runs its course with 
such rapidity that in a comparatively short time the patient is brought 
into the last stage. Under these circumstances the antiphlogistic 
plan only accelerates the fatal termination. No doubt in ordinary 
peritonitis bleeding may check the increase or extension of the dis- 
ease ; but in these cases the affection is immediately extensive and 
severe, and the indications are not to withdraw blood from the already 
enfeebled frame, but rather to relieve pain, control the peristaltic 
action of the bowel, and to support the strength until nature shall 
have completed the organization of the false membrane. 

In the epidemic of 1827 the antiphlogistic method in these cases 
signally failed in our wards, while the exhibition of opium and wine, 

1 "Clinical Report of the Meath Hospital," Dublin Hospital Reports, vol. v. 



INTESTINAL HEMORRHAGE. 235 

or of opium in full doses, was attended by satisfactory results. More 
recent experience testifies largely to the truth of these observations. 

Dr. Samuel Ousack, in speaking of puerperal fever, long ago bore 
witness to the efficacy of wine and opium in puerperal peritonitis, 
where the powers of life were greatly sunken, and any form of blood- 
letting or of depletion was inadmissible. His observations were fully 
confirmed by Dr. Gooch. 

I would commend to your most attentive consideration the following 
admirable remarks by Dr. Murchison on the treatment of peritonitis 
in fever. He says: — 1 

" Although the cause of peritonitis cannot always be determined with 
certainty, in the great majority of instances it is perforation of the bowel. 
The case, though desperate, is not altogether hopeless. Opium is the only 
remedy to be relied on in such cases ; but, to be of service, it must be given 
immediately and boldly. To an adult, two grains of solid opium may be 
given at once, followed by one grain every second or third hour, till slight 
stupor is induced. When the stomach is irritable, the subcutaneous injection 
of morphia is preferable to opium by the mouth. The doses will vary with 
the age and other conditions of the patient, but the amount of opium tole- 
rated is often extraordinary ; as much as sixty grains have been taken in 
three days with benefit. The opium is to be given alone, and not in combi- 
nation with calomel, which brings down more bile into the lower bowel, and 
so excites peristaltic action. The object is not to produce absorption of 
lymph (even if the mercury had power to do this), but to paralyze the 
movements of the bowels, so as to prevent the escape of their contents into 
the peritoneum, and favour the formation of adhesions. 

" Many writers have recommended the application of leeches to the abdo- 
men on the supervention of peritonitis, but the extreme prostration, and the 
circumstance that the tendency is to death by asthenia, contraindicate such 
a practice. The pain and tension of the abdomen will also be relieved by 
warm fomentations, bran poultices, and turpentine stupes ; but a much more 
certain method of subduing the inflammation is covering the abdomen with 
a bladder of ice, or with the ice poultice referred to under the treatment of 
tympanites. At the same time the patient must be kept in a state of absolute 
rest, and on no account raised in bed, and the ingesta ought to be liquid, 
and given in such small quantities at a time that they can be absorbed by 
the stomach. A tablespoonful of milk or of iced brandy and water may be 
given every hour, or every half-hour. The large quantities of food and 
stimulants sometimes given cannot fail, in my opinion, to be injurious." 

He adds : — 

" If the case does well, we must beware of interfering with the constipation 
induced by the opium : cases are recorded where the incautious administra- 
tion of a purge appeared to break up the adhesions and produce a fresh and 
fatal attack of peritonitis." 

Hemorrhage from the intestine in fever is not of very uncommon 
occurrence. It may sometimes be regarded as to some extent a cr'dl- 

« ' Loc. cit., page 655. 



236 LECTURES ON FEVER. 

cal phenomenon, and it often produces a beneficial and curative effect, 
lessening the local determination and irritation. Under these condi- 
tions it should not be interfered with. 

But cases are met with in which, from the amount, continuance, or 
recurrence of the bleeding, the patient's life is placed in jeopardy, 
and then we are called on to check the flow if possible. 

The manner of the hemorrhage is twofold. Sometimes it consists 
in a weeping from the mucous membrane. More rarely a vessel of 
some size is opened by ulceration — this especially happens in the 
second or third week of enteric fever. Fortunately, the treatment 
likely to be of use is nearly the same in both cases. Rest is of para- 
mount importance. Cold drinks and ice may be given. Turpentine, 
in small doses, is particularly useful where the hemorrhage is associated 
with much tympany. Acetate of lead and opium sometimes act well; 
or opium may be given in full doses if there are strong grounds for 
supposing that the source of the bleeding is an eroded artery. The 
points in favour of such a view will be the suddenness of the occur- 
rence of the bleeding, its large amount, the advanced period of the 
illness, and the absence of hemorrhages in other parts of the body. 

A man, of middle age, was almost convalescent from a compara- 
tively mild enteric fever, when in the middle of the night he was 
seized with sudden diarrhoea. The resident clinical clerk was hastily 
summoned. He soon found that the motions consisted principally of 
blood, at first dark and tar-like, then of a more florid and arterial 
appearance. The quantity passing from the patient was so large that 
no time was to be lost. The clinical clerk accordingly at once ad- 
ministered a full opiate; in an hour he gave a grain of opium with 
acetate of lead, and he repeated this dose every two hours until the 
patient had taken 7 or 8 grains of crude opium. The hemorrhage 
was soon checked, and the curious thing is that the patient showed 
the same remarkable tolerance of the opium which we have already 
spoken of in connection with peritonitis. He made a good and rapid 
recovery. Of course the utmost caution should be employed in these 
cases, aud the effect of every dose should be attentively watched. 

Among other remedies in this complication may be mentioned tan- 
nin, tincture of the perchloride of iron, and ergot. The last is highly 
commended by such authorities as Dr. Murchison, and Dr. J. B. Rus- 
sell, of Glasgow. The former has used it subcutaneously with excel- 
lent effect. 



NERVOUS SECONDARY SYMPTOMS OF FEVER. 237 



LECTURE XX XII. 

Treatment of the Nervous Secondary Symptoms of Fever — Headache— Cold lotions, 
warm fomentations, moderate leeching, shaving the head, cold affusion, ice — 
Delirium — Treatment depends on (1) period of case, (2) presence of hyperemia 
of the brain, or otherwise — Ice, leeches, shaving the head, cold affusion in active 
delirium — Nourishment and wine in passive or anaemic delirium — Sleeplessness — 
Moderate leeching, cold affusion, ice— Turpentine in constipation and tympany — 
Catheterism in distended bladder — Sedatives — Opium, tartar emetic and opium, 
hyoscyamus, bromide of potassium, chloral, wine — Convulsions — Most formidable 
in fever — TJrsemic, due to (1) retention of urine: catheterism; (2) suppression of 
urine : dry-cupping and poulticing over kidneys, diluents, diuretics, aperient ene- 
mata, promotion of action of the skin. 

Among- the earliest, most frequent, and often most prominent of 
the nervous symptoms in fever is headache. At first it is seldom 
very violent, and no important or vigorous measures are required 
for its relief at this period. It is generally a symptom which sub- 
sides early in the case, and is rarely indicative of anything beyond 
functional derangement, or incipient or progressive affection of the 
brain. The intensity of the symptom is more marked in typhus 
than in typhoid; but in neither form of fever is it often accompanied 
by indications of active determination to the head, and in both it 
commonly subsides without any interference beyond the application 
of a cold lotion, such as vinegar and water, or chloride of ammonium 
(sal ammoniac) and water. 

But should it be severe, and attended with more or less heat of the 
head, you may employ with advantage warm stuping of the forehead 
and temples. These warm fomentations may be repeated according 
to circumstances, and you have often seen the marked relief afforded 
by them. Should this measure fail, the application of two or three 
small leeches to the temples or behind the ears will be followed by 
relief — a relief out of proportion to the quantity of blood taken. You 
will, however, remember that the pain generally subsides by itself 
after the lapse of a few days. Yet it sometimes continues, and resists 
even the treatment I have suggested; and then, when it is severe and 
attended with heat and fulness of the head, you may adopt more 
active measures. You may apply a larger number of leeches in 
relays for two or three times. It used to be the practice in this city, 
when the pain was obstinate, with heat of the head, sleeplessness, and 



238 LECTURES ON FEVER. 

commencing delirium, to open the temporal artery — a proceeding 
often followed by excellent results. It should be remembered that T 
speak of a time at the commencement of the change of type in 
disease; yet the general adoption of this measure is not to be advised, 
as the wearing of a tight ligature round the head is often distressing, 
to say nothing of the accidental re-opening of the wound or the for- 
mation of a small traumatic aneurism. I should tell you that the 
quantity of blood removed in this procedure was never excessive, 
varying from six to ten or twelve ounces. 

Now, I believe that by shaving the head, the cold affusion, and, if 
necessary, the application of ice, you will do all that arteriotomy 
could effect. 

Yet shaving the head should not be a matter of routine, especially 
among hospital patients. You must not forget that the poor conva- 
lescent cannot afford to purchase a wig, and that in consequence he 
may become liable to otitis and other accidents, such as rheumatism 
or neuralgia of the head. And this reminds me that in the epidemic 
of 1826 and 1828 one of the physicians of our large temporary hos- 
pital adopted the routine practice of shaving the head of almost all 
his patients. Dr. Graves and I, on the other hand, had very rarely 
occasion to direct the operation, so that when the shorn and the 
unshorn patients met in the convalescent wards the former became 
greatly dissatisfied. But this was not all, for soon those whose heads 
had escaped the routine razor turned on the shaved ones such a 
battery of Irish satire on their appearance that on one occasion it 
proved too much for endurance, and a general engagement took 
place in the convalescent ward, which was quelled with the greatest 
difficulty. 

Cold affusion is best carried out in the following manner : The 
patient's head is held over a basin, while cold water is allowed to 
pour slowly from a jug holding a quart or two, and held at no great 
height above the head. It is necessary to let the stream fall on 
different parts of the head from time to time, for otherwise a very 
painful sensation may be produced. The almost instantaneous relief 
afforded in this way is often remarkable. 

Now as to the application of ice: This is frequently most clumsily 
and ineffectually performed. A bladder containing fragments of ice 
is placed on the vertex and allowed to remain there. The effect of 
the cold thus locally employed on the shaved head gives such distress 
as to be at times intolerable until the ice is all melted, when you may 
frequently find your patient's head covered for hours with a bag of 
water at fever heat. Of course you will not permit such an error to 



TREATMENT OF DELIRIUM. 239 

happen — the frequency of which showed how much we were in want 
of skilled nurse-tending. The proper method of proceeding is to place 
a piece of ice, rubbed smooth with the hand, in a cup-sponge of con- 
venient size, and by inverting the sponge to bring the ice into contact 
with the shaved scalp, keeping it in gentle motion round the head. 
The sponge absorbs the water, and when it is saturated it can be 
squeezed out, the ice replaced, and the application recommenced. In 
this way no pain is caused, and the proceeding is grateful to the 
patient, while the entire head is cooled. Of course, in many cases the 
application must be renewed at shorter or longer intervals. 

Before passing from the treatment of headache I wish to mention 
the influence for good on the general condition of the patient often 
observed on cooling of the head by some of the means I have described. 
At times, in advanced fever with continued determination to the head, 
you may see a rapid improvement (which continues to recovery) of 
the patient when the heat and fulness of the head have been allayed 
by appropriate measures. It seems as if the influence of periodicity, 
which had been interrupted by the local malady, was again permitted 
to act. There can be no doubt of the existence in fever of a condition 
more or less persistent, in which various influences may bring about 
a cessation or subsidence of the morbid phenomena. Thus we read 
of cases of camp fever subsiding on any forced removal of the patients. 
You will find marked benefit to follow the removal of a patient in 
protracted fever to another ward; and even crisis has been observed 
closely following a simpler proceeding, such as a change into a fresh 
bed, the washing and shaving of the patient's face, sponging the sur- 
face, and so on. 

In considering delirium in fever, strive to keep the great patho- 
logical principle before you of the rarity of actual cerebritis in essen- 
tial disease. Also that when it does occur it is in most cases specific 
and reactive, and as such, not to be treated as a simple primary in- 
flammation. You will do well to study Dr. Collins' history of the 
epidemic of cerebro-spinal fever in Dublin — the so-called "cerebro- 
spinal arachnitis" — and you will perceive, I do not doubt, that the 
condition of the brain and spinal cord was strictly analogous to 
that of the ordinary secondary diseases in typhus and typhoid fevers; 
tbat it bore the same relation to the essential malady; and that 
in all things — treatment included — there was an analogy between 
the local and predominant affections of these forms of disease. They 
differed only as to symptoms referable to the organs which bore the 
weight of the secondary malady, and agreed in inconstancy of occur- 
rence, variety in degree, and incompetency of the local phenomena 
to account for the general symptoms. 



2-10 LECTURES ON FEVER. 

A key to the treatment of delirium is to be obtained by having 
regard mainly to two considerations. First, the period of the case at 
which this symptom is developed. The earlier the period, the greater 
the chance of relief by remedial measures, such as the cold affusion 
and leeching. Secondly, the presence, the degree, or the absence of 
signs of active hyperemia of the brain. 

Now, the symptom may be actively developed at an early period, 
making it probable that it is still of toxic and functional origin; or 
it may occur at a more advanced stage, when — if signs of active 
determination to the head .be present—it may be supposed that re- 
active irritation is already set up. It is in this latter condition that 
Dr. Hudson advocates the practice of arteriotomy, but this measure 
is seldom necessary if leeches are judiciously used, and the cold 
affusion or the application of ice to the head properly carried out. 

Ice is especially useful under such circumstances. I remember 
attending a professional man, who with a very large head was of a 
highly nervous and choleric temperament. He had a well-marked 
typhus fever with severe cerebral symptoms, such as frequently-vio- 
lent delirium, long-continued want of sleep, and extreme heat of the 
head. Leeches had been freely applied, and followed by shaving the 
scalp and cold affusion. I recommended the application of ice in 
the way I have detailed to you. There had been no sleep for several 
days and nights. A proper supply of ice having been obtained, his 
wife commenced to move the sponge with ice slowly and steadily 
round and round and over the great head. The patient at once 
became quiet, and soon fell into tranquil sleep. So long as the appli- 
cation was continued he remained asleep, but awoke suddenly and 
delirious whenever from fatigue his wife rested her arm. In this 
way he used to get continuous sleep for half an hour or an hour. 
For three days and three nights she hardly ever intermitted her labour 
of love, and might be seen kneeling at the bedside while a cloud of 
vapour was rising from the head. Her unwearied efforts were re- 
warded, and her husband recovered. 

The devotion of woman is truly wonderful. In another case — one 
of putrid typhus fever — the disease, from the condition of the skin 
and the discharges, was of a most loathsome nature, and the patient, 
also a medical man, in his wild delirium could not be kept in bed 
unless his wife undressed and lay down beside him. This, I ascer- 
tained, she continued to do during the long course of the disease, for 
in this way alone could any sleep be obtained. At our daily visit 
this lady received us in a fresh and elegant morning costume. She 
too had her well-earned reward, and we cannot doubt that her noble 



DELIRIUM AND SLEEPLESSNESS. 241 

indifference to personal risk went far to protect her in the dreadful 
exposure to contagion. A lesson taught us is that contagion is one 
thing, the state of receptivity of the body another. 

Gentlemen, you will learn many things in your future practice 
besides medicine, and will be taught what a woman will do when the 
object of her love lies prostrate in disease, in shame, in sorrow, or in 
madness. This is indeed the bravery of devotion. In one of the 
Ballads of the Cid, he is represented as rescuing from death by drown- 
ing a leper whom none of his train would approach. He mounts him 
on his horse, brings him to a place of refuge, and even shares his bed 
with him at night. He is awakened by a sensation as if a sword 
passed through him, to find his companion gone. Soon afterwards 
the room is suddenly filled with light, and the holy Lazarus stands 
effulgent by his side, bringing a message from the Throne of God, 
that all honour will be given to him in this world, death in victory, 
and life eternal in the world to come. 

The form of delirium I have just been speaking of is that accom- 
panied, by high arterial tension and other active symptoms. If, on 
the other hand, such signs are wanting, you must be very cautious in 
bleeding locally, or even in the application of cold. An opposite line 
of treatment is in this case generally indicated. If we have delirium, 
even violent, without heat, fulness, or increased arterial action, the 
treatment by leeching and cold may be in the highest degree danger- 
ous. This we have often witnessed in pure delirium tremens, and in 
the frequent affection in Dublin called "the whiskey-fever," when 
these are combated by depletion of the head. 

It is now many years since I was called to see a Polish officer in an 
advanced stage of typhus fever. He had been very delirious, and at 
my visit I found him with his shaven head covered by a bladder of 
ice, while in each axilla a large mass of ice was fixed, and his hands 
were clasped as in prayer. He was perfectly pale, and with great 
feebleness of pulse; but he recognized me, and turning towards me 
he mournfully said, " I think I am one of the lost ones." I need not 
say the ice was all removed, warm and dry clothing supplied, while 
wine and nourishment were given. The result of the change of 
treatment was in every way satisfactory. 

In administering stimulants in delirium you must in every case 
begin tentatively, watching their effect from hour to hour. The chief 
indications for their employment are the nature and the advanced 
period of the fever, the absence of signs of active determination to the 
head, the want of vigour in the heart as to its impulse and the intensity 
of its sounds, and, lastly, the age and previous history of your patient. 
16 



242 LECTURES ON FEVEK. 

With regard to this last point, you will remember what I have said 
in a former lecture as to the sanative influence of stimulauts so often 
observed in patients of previously temperate habits. 

The question of the exhibition of sedatives in delirium may fitly 
be considered in connection with the treatment of insomnia, or sleep- 
lessness, to which I would now bespeak your attention. The symp- 
tom is frequently one of the most serious, troublesome, and unmanage- 
able of the evidences of nervous derangement in fever. It is sometimes 
combated successfully by such measures as have been already 
considered — namely, moderate leeching, the cold affusion, and the 
application of ice. In cases where the bowels are confined with more 
or less tympany, Dr. Hudson states that the best effects were produced 
by the administration of a full dose of turpentine. I have myself ob- 
served a like result follow the relief of some local distress in a distant 
part of the body. A man in advanced fever, who had been sleepless 
and very delirious, was found to labour under a distended bladder. 
The catheter was at once passed, and an immense quantity of urine 
drawn off. Very shortly the delirium ceased and the patient fell 
asleep. 

It remains for us to speak of sedatives in fever. 

In seeking for a guide as to the exhibition of opium you will find 
assistance in observing the state of the eye, for the contracted or " pin- 
hole" pupil seems to be more closely related to active hyperaemia of 
the brain than the natural or dilated one. Still, the condition of the 
pupil is not an absolutely certain guide, and cases are recorded in 
which an opiate acted well notwithstanding its contraction. This sign 
also may be present in one eye and absent in the other. Speaking 
generally, it is far safer in fever to give opium in small and repeated 
doses than to venture upon a large single dose. It may be advanta- 
geously combined with antimony, as advocated by Dr. Graves, not so 
much as an antiphlogistic or eliminative agent, but as a direct means 
of increasing the hypnotic influence of opium. This appears to be 
one of those therapeutic results, the explanation of which, like that 
of many others relating to the action of medicine, is so far involved 
in obscurity. Dr. Graves used to prescribe a mixture containing 
four grains of tartar emetic and a drachm of tincture of opium in 
eight ounces of camphor water. A tablespoonful of this was given 
every second hour until the desired effect was produced. The efficacy 
of the remedy in his hands was most remarkable ; and in the number 
of the Dublin Quarterly Journal for August, 1849, Dr. Robert Law 
bears his testimony to the value of this treatment. 1 

1 Second Series, vol. viii. p. 63. 



SEDATIVES IN FEVER. 243 

Tartar emetic and opium are in general indicated in those cases of 
even high delirium, with sleeplessness, where the head is cool and 
the action of the heart is not vigorous. 

Other sedatives which you will find of use in fever are the tincture 
of hyoscyamus, bromide of potassium, and chloral. With respect to 
the last-named remedy, I would caution you against giving too large 
a dose at once. In fever ten or fifteen grains of the hydrate of chloral 
are generally sufficient to produce the wished- for effect, and if this 
dose fails it can be repeated after a lapse of one or two hours. The 
remedy is of especial value in the management of many cases of 
simple delirium tremens. In this disease it may be employed in 
moderate and repeated doses if necessary. 

You will occasionally find that wine has a well-marked calming 
and sedative effect in fever. A patient who has been restless, sleep- 
less, and delirious will sometimes become quiet and fall asleep after 
the administration of a little wine. This occurs where the nervous 
symptoms are probably clue to an anaemic or spansemic condition of 
the brain associated with a weak heart and a flagging circulation. 

Convulsions in fever are among the most formidable complications 
of the disease, more particularly so when they occur in its advanced 
stages. Under the term "convulsions" may be included a group of 
phenomena varying from slight subsullus iendinum and floccitatio, or 
picking at the bed clothes, to the most violent and general pertur- 
bation of the muscular system. These symptoms in a more advanced 
stage of the fever are often attributed to urasmic poisoning, and there 
can be no doubt that there is frequently disturbance referable to the 
urinary organs. You will see in Dr. Hudson's work 1 a quotation 
from Sir Dominic Oorrigan in reference to the importance of atten- 
tion to the relieving of the bladder. Sir Dominic shows that daily 
attention to the state of the bladder is imperatively necessary, and 
that the catheter should be employed in retention of urine with or 
without dribbling. In truth, you must not trust to any report from 
the nurse as to the existence or absence of retention, for often, 
although a large quantity of water may have been passed, the bladder 
will be found greatly distended. This state may have been preceded 
by suppression, and it sometimes happens that the return of the 
secretion is attended by an enormous flow, especially when this 
occurs at a critical time of the fever. In such a case it will be right 
for you to revisit the patient within an hour or two after catheterism, 
when you may be surprised to find the bladder again over-distended. 

1 Lectures ou the Study of Fever, second edition, p. 183. 



244 LECTURES ON FEVER. 

The amount of distension is sometimes extraordinary. " I saw not 
long since, in private practice," says Sir Dominick Corrigan,in speak- 
ing of the necessity of attending to the bladder in fever, " another 
case illustrating the same point. In this case the patient was a lady 
under the care of a homoeopath. You know a homoeopath would 
not use a catheter. It was on the fifteenth or sixteenth day of fever. 
I found her in epileptic convulsions, which had continued for some 
hours, foaming at the mouth, insensible, unable to swallow, and, to all 
appearance, dying. On examining the abdomen, I felt the bladder 
extending up as high as the umbilicus. On introducing the catheter, 
it was scarcely possible to bear the intolerable ammoniacal smell of 
the urine, which must have been shut up for several days. It con- 
tinued to flow until some large basinfuls were drawn off. This patient 
recovered, but she suffered much from the neglect. Subacute and 
then chronic cystitis followed, under which she continued to suffer for 
more than a year afterwards." 

In connection with the presence of uraemia in fever we have 
observed the urine in such cases to effervesce briskly on adding a 
dilute acid, and I have already mentioned a case of extreme subsultus 
in which the cerebral sinuses and the veins of the pia mater contained 
air in considerable quantity. 

The most long-continued and violent attack of convulsions I ever 
witnessed was in the case of a student of this hospital, who had gone 
on to the thirteenth day of fever. The distended bladder could be 
felt; but such was the violence of the convulsions, attended with 
extraordinary priapism, that all attempts at catheterism were futile. 
It was also impossible to get the patient to swallow anything, or to 
use an enema, and under these desperate circumstances we determined 
to employ chloroform inhalation. The greatest difficulties attended 
the administration, but at last the effect was produced. The convul- 
sions ceased like magic, and suddenly a jet of urine sprang upwards 
to a great height from the still erect penis; the stream continuing to 
flow until the bladder was empty, when the priapism disappeared. 

We see, therefore, that, where the uraemic condition and its accom- 
panying convulsions depend on mere retention of urine, we have a 
ready and efficacious remedy in careful and judicious evacuation of the 
bladder by the catheter. 

But in suppression of urine our treatment must be different. Dry- 
cupping freely employed over the kidneys, the diligent application 
of poultices and sinapisms in the same region, the use of diluents, and 
the exhibition of a combination of nitre with the spirit of nitrous 
ether, are the measures in which you are to place most confidence. 



PHLEGMASIA ALBA DOLENS. 245 

It is also necessary to keep the bowels open by turpentine enemata, 
and the action of the skin may be stimulated by sponging with tepid 
vinegar and water and subsequent rubbing with a dry towel. 



LECTURE XXXI II. 

Phlegmasia Alba Dolens— The swelling is not always painful, or white in appear- 
ance — Symmetry of the affected limb not lost — Professor Trousseau's views as to 
the etiology of the affection — Phlegmasia (1) of puerperal women, (2) in scrofu- 
lous and (3) cancerous cachexia — Pulmonary embolism caused by phlegmasia — 
Case of phlegmasia after typhus fever— Treatment of the affection — General Con- 
clusion. 

Gentlemen, you may remember my mentioning to you that a 
continued rapidity of pulse after the other constitutional symptoms 
of fever had subsided was to be taken, not — as suggested by Laennec 
— as a sign that the heart had been weakened, but rather as showing 
the existence of some acute organic change attended with irritation. 
I mentioned as examples of these changes two pathological condi- 
tions — one, the acute and sometimes general development of tubercle; 
and the other, that form of disease to which the name of phlegmasia 
dolens, or phlegmasia alba dolens, has been given. 

We shall by-and-by examine how far the term " phlegmasia" is 
properly applied; and, although the disease is commonly more or 
less painful, it may occur so free from local suffering that its discovery 
is accidental; and so, as I have already shown, the adjective "dolens" 
is not always applicable. Again, in place of the swelling being 
colourless, the entire limb may be covered with deep purplish-blue 
arborescent stainings, so that the remaining portion of the term is 
not always appropriate. This, however, is less often met with than 
the absence of pain. The pain, too, may be singularly localized; 
thus, in a case which was under the care of an eminent physician, the 
pain was confined to the sciatic notch. The disease was held to be 
merely sciatica, and the actual cautery ordered to be applied over the 
nerve. In preparing to effect this the assistant accidentally exposed 
the opposite extremity, when he was struck by its comparative ema- 
ciation, and the real nature of the case was at once revealed. 

This illustrates an interesting circumstance, which we have often 
observed — namely, that, though the swelling of the limb may be 
general, it has little if any effect on the symmetry of the part. The 
limb is simply larger and fuller than the opposite extremity, so that 



246 LECTURES ON FEVER. 

it is often only by comparison that the morbid enlargement is recog- 
nized. I detailed to you a case in which symptoms of intermittent 
fever, which, however, was then epidemic, were present and exaspe- 
rated by the use of quinine. Here the discovery of the nature of the 
disease was due solely to an accidental comparison of the lower ex- 
tremities. The patient was not conscious of the existence of any 
enlargement or pain in the limb. 

It is probable that this remarkable appearance of symmetry of the 
affected limb occurs more frequently when the disease is a sequela of 
fever than in other cases. Thus Professor Trousseau, 1 in speaking 
of its occurrence in tubercular and cancerous cachexias, refers to the 
irregular form assumed by the painful oedema in these affections. 

In his lectures the same great clinical teacher dwells on phlegmasia 
alba dolens as a result of puerperal fever, and also mentions its occur- 
rence in typhus and in typhoid fevers. 

He inclines to the opinion that it results rather from a condition 
of the blood predisposing to coagulation in the veins, and their con- 
sequent obstruction, than to primary phlebitis. The result is what 
he denominates "painful oedema," which disappears either by the 
establishment of a collateral circulation or by the resolution of the 
clot. He gives some important facts showing that the existence of a 
phlegmasia abla dolens may have an important influence in the diag- 
nosis of visceral cancer. 

You may now ask how far the term " phlegmasia" is applicable to 
this disease, or whether the coagulation of blood in the veins is not 
the first step of the local malady, while the inflammatory condition is 
secondary and reactive. Certain it is that when a cordy and painful 
state of the veins, such as the femoral or saphena, exists, the moderate 
use of leeches over the vessel is advisable. This is true at least in 
the case where the disease occurs as a sequela of fever, and it is on 
this that our observations are based. 

Now, whether phlegmasia occurring in puerperal woman is or is 
not due to the presence of uterine phlebitis and the extension of in- 
flammatory action along the veins, producing obstruction of them, 
may be a question ; but that actual primary or traumatic phlebitis is 
capable of obstructing a vein so as to cause painful oedema— in other 
words, phlegmasia dolens — appears from a case which occurred some 
years ago in our wards. It was of a patient labouring under an acute 
attack of visceral inflammation who was bled from the arm. The 
operator used a rusty and blunt lancet. The arm became painful and 

1 Clinical Medicine, vol. v. lect. xcv. New Syd. Soc. Translation. 



THE BLOOD IN PHLEGMASIA. 247 

tender along the course of the median basilic vein above and below 
the bend of the elbow. There was no swelling, but the type of fever 
changed to an asthenic form, attended by sweating and anxiety, so 
that the state of pyaemia was apprehended. This having continued 
for a few days, the arm suddenly swelled from above the elbow down- 
wards, and presented all the characters of phlegmasia alba dolens. 
The constitutional symptoms subsided, and the patient gradually 
recovered. 

Now, you know that ordinary phlegmasia dolens is seldom a fatal 
disease, a fact which may be accounted for by assuming that, as in 
the cachexias, the coagulation of the blood is the principal morbid 
condition, or that it acts in preventing the blood-poisoning by the 
localization of phlebitis. Be this as it may, it seems certain that the 
danger is inversely as the amount of swelling. I believe that in the 
case I have just now detailed suppurative inflammation of the vein 
was about to commence when coagulation put an end to further 
absorption. 

In connection with this point I may notice that in certain forms of 
visceral irritation the bulk of the affected organ is greatly augmented. 
And it may be that this is caused by oedema, the result of venous 
obstruction. Thus in a case of croupous or plastic pneumonia which 
was brought before the Pathological Society of Dublin by Professor 
Eobert William Smith the enlargement of the affected lung was so 
considerable as to simulate empyema ; the side was much dilated and. 
the liver depressed. Every air-cell seemed to be filled with minute 
granular fibrinous bodies, of which thousands were obtainable by 
washing the cut surface of the lung. 

Trousseau has shown that the principal condition in the phlegmasia 
dolens is coagulation of blood in some venous trunk, and not, as has 
been held, an affection of the lymphatics. In this hospital we have 
verified his statement of freedom of the lymphatics and glands in the 
groin. You will do well to study his 95th lecture, in which, in addi- 
tion to an exhaustive pathological account of the disease, he shows 
that, in the cachexias generally, hasmatologists 1 have established that 
there is a diminution of the red globules and an augmentation of the 
fibrin and serum of the blood. This condition predisposes to a spon- 
taneous coagulation, the tendency to which we may well suppose to 
be still further increased by the presence of any phlebitio irritation. 

I have told you that Trousseau explains the frequency of phleg- 

1 Andral et Gaverr«t, Rucherches Bur lea Modifications des Proportions des quolques 
Prineipes du Sang daus les Maladies. Paris, 184'J. 



248 LECTURES ON FEVER. 

masia in the cancerous and tubercular cachexia? by a reference to this 
fibrinous and leucaematous condition of the blood, and it is more 
than probable that its occurrence as a sequela of fever depends on the 
same cause. In further support of this view I may recall the fact, 
also noticed by Trousseau, that phlegmasia is more common after 
enteric than after typhus fever, the longer duration of the former 
tending to modify the constitution of the blood to a greater degree. 
There can be little doubt also that the local abdominal irritation so 
common in the advanced stages of enteric fever, like the uterine 
irritation in cases of phlegmasia puerperarum, acts as an exciting 
cause in the presence of such a deteriorated condition of blood. 

Viewing the question again from another point, it may be held 
that the affection following fever is the result rather of a state of 
blood predisposing to coagulation than of an original phlebitis. It 
has been observed that there is often little, if any, increase of local 
temperature, and the disease appears to differ from the secondary 
affections of fever in not presenting any well-marked signs of pe- 
riodic retrocession. Still, as I have said, in cases where at an early 
period a cordy state of the femoral or saphena veins — accompanied 
by tenderness — exists, the application of a few leeches along the 
course of the vessels, fomentations, poultices, and the moderate use 
of opium are followed by good effects. 

Professor Trousseau also alludes to the occurrence of pulmonary 
embolism in phlegmasia dolens in the male subject, showing that 
spontaneous coagulation may be developed in the saphena, crural, or 
any other vein, and remain limited to a very small extent of the 
vessel. He observes that generally the migratory clot reaches the 
lung, causing dyspnoea and rapid death by apnoea; but he believes 
that in certain exceptional cases the clot may be arrested in the right 
auricle or ventricle of the heart. He says that, in accordance with 
the predisposition of the patient and the volume of the clot, the 
phenomena which belong to syncope will be observed ; the heart, 
surprised, so to speak, by the arrival of the migratory clot, will at 
once cease to beat with regularity and power, and ere long contrac- 
tions will entirely cease. In these cases death will take place by 
syncope — by " arrest" of the heart — in fact, the prolonged syncope 
leads to death. 

I have sometimes thought that this form of syncope was induced 
less by the " surprise" of the heart than by the sudden cutting oft* of 
the blood supply from the left ventricle. A case was some years ago 
presented to the Pathological Society of Dublin in which symptoms 
of heart disease were at last followed by a sudden and fatal syncope. 



CASE OF PHLEGMASIA DOLENS. 249 

An indurated coagulum of a spherical form had entered the funnel- 
shaped sinus described by Mr. Adams, and completely occluded the 
left auriculo-ventricular opening, thus absolutely and suddenly cutting 
off the blood supply from the left ventricle. 

Before I conclude this lecture I will read the notes of a very inter- 
esting case of the affection which has been engaging our attention- 
The subject of it was a pupil of Dr. Graves and myself at this hospital) 
who for many years since has enjoyed an extensive practice in the 
country. The facts of the case are given in the gentleman's own 
words. He says : — 

For a great part of the years 1827, 1828, and 1829, I acted as clinical 
clerk to you and our lamented friend Dr. Graves in the Meath Hospital, 
during the protracted continuance of an epidemic of typhus fever, which we 
cannot easily forget. My principal business was to ascertain, as far as 
possible, the critical days of the fever, in the investigation of which you and 
Dr. Graves were deeply interested at the time. In this occupation it was 
my duty to spend several hours every day at the bedside of patients in all 
stages of the fever, and my immunity from contagion for so long a period 
led me to imagine that I had become absolutely fever-proof; but I was des- 
tined to be undeceived. 

One morning in June, 1829, Dr. Graves called the attention of the class 
to a remarkable instance of color mordax in a female patient. Of course 
there was a rush of the pupils to witness this unusual phenomenon, myself 
amongst the foremost. I had no sooner laid my hand on the burning skin 
of the patient's arm than I was conscious, by a sudden thrill or shock through 
my whole frame, that I was stricken by fever. That day and the next con- 
stituted the period of incubation. I was not actually ill, but I was languid, 
uncomfortable, listless — out of sorts in every way. On the third day I had 
a rigor, followed by an intense pain in the head, with nearly all the usual 
characteristics of typhus, including a full crop of petechias. (It is worthy 
of notice, however, that neither in this nor in several subsequent fevers had 
I ever the slightest delirium.) On the twenty-first day from the rigor I ap- 
peared to have a crisis, and a terrible crisis it was. I was suddenly seized 
with violent pain, apparently in the left hip-joint, and gradually extending 
to the leg and foot. The whole limb became swollen and glazed, presenting 
all the appearance of a leg affected with pMegmasia dolens, as no doubt it 
was. The pain was excessive and almost intolerable. For fourteen nights 
the most powerful opiates which could be safely administered failed to pro- 
cure sleep, though they served, in some degree, to alleviate pain. 

After about three weeks of acute suffering — six weeks from the commence- 
ment of the fever — I was enabled to leave my bed. But the swelling of the 
limb remained, and it was evident that there was permanent hypertrophy of 
the cellular substance. In all likelihood I was doomed to have a thick leg 
for life. For many years, too, I continued to have more or less pain in the 
hip, always increased by exercise. Some short time after my recovery from 
the fever the veins of the affected leg became varicose, and I had a varicose 
ulcer which remained open for nearly two years. This, however, was healed 
under the influence of country air and consequently improved health, and it 
has never returned. Once — about twenty years ago — a vein burst, and I 
lost a considerable quantity of blood. Since then 1 have persistently worn 
a bandage, and the veins have given me little further trouble. No special 



250 LECTURES ON FEVER. 

remedies were adopted for the reduction of the swelling of the leg; but on 
one occasion Dr. Graves hesitatingly suggested a line of treatment to which, 
as it involved an undesirable contingency, I demurred. 

I now come to a curious and interesting phase of the history of this thick 
leg. You recollect that the swelling of the leg appeared to be a sequela of 
one typhus fever. Exactly thirty-one years afterwards — that is to say, in 
June, 1860 — I had another typhus fever, when you and Dr. Hudson kindly 
came to the country to visit me. (Bow I came to pick up this well-marked 
maculated typhus I never could divine. There was no epidemic fever of 
any description in the neighbourhood, nor had I seen a case of typhus for 
seven years.) Well, the result of this fever was to restore my thick leg to 
its original dimensions. There was no marked crisis. After two or three 
weeks of extreme danger, in which my life hung by a thread, the fever 
gradually subsided, and disappeared by the twenty-seventh or twenty-eighth 
day, leaving the affected leg as slim and emaciated as its fellow ; and the 
hypertrophy has never since reappeared. 

But this is not all. In the spring of the present year (1813) I had a 
severe attack of influenza, from the effects of which I have not even yet 
recovered. After two or three months of delicate health, during which my 
professional engagements prevented my having change of air, a blush of 
redness appeared over the middle third of the tibia of the varicose leg, 
accompanied by tingling pain, tenderness to the touch, and slight cedema 
of the leg. The redness gradually increased from day to day in extent and 
intensity, and from its upper margin a well-defined dark red line extended 
to the knee, where it abruptly terminated. Under the use of bark and 
iodide of potassium the redness and tumefaction subsided, and I then de- 
tected a hard ridge, apparently bony, and about three-fourths of an inch in 
length, on the inside surface of the tibia. At first I attributed these symp- 
toms to periostitis; but when the cedema had almost entirely disappeared, I 
discovered that the " ridge" which I had believed to be bony was not bone 
at all, but a portion of obliterated vein like a piece of hard whip-cord and 
movable under the finger. Was this an attempt at a natural cure ? I 
sometimes fancy that the varicose veins have diminished in fulness and bulk, 
though it may be only fancy. 

Before I conclude I may be permitted to refer to a couple of facts which 
bear upon the vexed question of a change of type in fever and other dis- 
eases. 

1. I was never strong or robust, and at the commencement of my first 
typhus fever, at the age of twenty-three, my health had been impaired by 
arduous study and close attendance on patients in a hospital atmosphere. 
And yet the treatment — which I maintain was at that time the correct and 
proper treatment — would not be adopted at the present day. After an 
unsuccessful attempt by poor Dan Pakenham (the worthy apothecary of the 
Meath Hospital) to open my temporal artery, a dozen leeches were applied 
for the relief of the pain of my head; and during the whole progress of this 
petechial fever I obstinately and successfully refused to swallow wine or any 
other stimulant whatever. Again, after twenty-one days' reduction of 
strength by typhus, and when phlebitis set in, I had a hundred leeches, in 
two relays, applied to the painful hip — without much apparent benefit, I 
admit, but still without killing me or causing any perceptible injury. What 
would happen under similar circumstances now? 

2. I was placed under much more favourable circumstances when, at the 
age of fifty-four, I was attacked by my second typhus fever. I had pre- 
viously been in good health, and was residing in pure country air. Never- 



TREATMENT OF THE AFFECTION. 251 

theless it was only by the continuous and lavish administration of stimulants 
— alcoholic and diffusive — that my life was saved. I offer no comment; is 
comment needed? 

In this very remarkable case there are two circumstances of pecu- 
liar interest. One of these is the undoubted occurrence of a second 
typhus fever in the same individual after a long lapse of time, the 
malady setting in, in the absence of any of its presumed exciting 
causes; the other, the fact that the tumefaction of the limb, which 
had been of many years' standing, completely subsided during the 
second fever. It is also worthy of note that last year my friend's 
health had not been so good, as a result of which a cachectic condition 
of blood was established, and determined venous coagulation in the 
leg. At least this would seem to be the probable explanation of the 
recent attack of irritation and coagulation in the vein of the leg. 

The treatment of this affection is sufficiently simple, and I have 
given you an outline of it as regards local measures. In the advanced 
stages the exhibition of iron is often most useful, the preparation on 
which I would specially place reliance being the " ferrum tartara- 
turn." 

In conclusion I would caution you against a possible error of diag- 
nosis. In phlegmasia, when the oedema in lessening loses a certain 
condition of tension, the local sensation of fluctuation singularly simu- 
lates that of an abscess, even one near the surface. This is often more 
or less localized, and the surgeon who neglects the history of the case 
and the attending phenomena may commit the error of taking a dif- 
fused cedema for a localized purulent collection. I have known an 
operation to be performed in two situations in the same extremity ; 
fortunately no bad result followed. A similar condition more com- 
monly observed is where parotid swellings form in connection with 
the eruptive fevers. I have seen deep incisions performed on the 
same occasion at both sides of the neck in cases where the sense of 
fluctuation solely was relied on. One patient died of oozing hemor- 
rhage under these circumstances, the bleeding setting every treatment 
at defiance. A fact such as this will show you that the caution I give 
is not unnecessary. 



252 LECTURES ON FEVER. 

Gentlemen, — We have now gone over the principal facts con- 
nected with the great subject of fever and its treatment, and have been 
much occupied with the local affections referable to one or more of 
the large cavities ; but I trust that the junior members of the class 
will not imagine that, as a rule, they are to put all the recommenda- 
tions given into force in any one case, or that I would encourage any 
meddlesome or complicated treatment in fever. There are cases in 
which you will have to change your hand several times in the course 
of the disease ; but the worst kind of physician is the man who, from 
his own timidity or want of confidence in himself, is constantly chang- 
ing his treatment and interfering with his case. You may still meet 
such practitioners — I regret to say it, too frequently — physicians, who 
have not learned to look at fever as a whole, who do not recognize 
the law of its spontaneous subsidence, or the great fact — especially as 
regards the nervous conditions — that the toxic state is to be looked to 
more than any supposed organic change. 

I remember a case of bad cerebral typhus attended by a gentleman 
who every day made a new diagnosis, and who at last gravely assured 
me that he had come to the conclusion that there existed acute inflam- 
mation of the hippocampus major ! 

You must engrave on your minds that fever, although often show- 
ing secondary functional or organic anatomical change, may run its 
course without such complications. In these simple, or so to speak 
normal, cases you have to see only that the patient is placed in the 
best condition as regards ventilation, cleanliness, and fitting nourish- 
ment ; that stimulants are given when indicated ; and that the state of 
the bladder and bowels is attended to. Should symptoms of local 
suffering occur, you are to meet them — at least in the first instance — 
as signs of functional rather than of organic disease, and seek to relieve 
them at the least expense to the system. You will remember what 
has been so often impressed on you here and in the wards — always to 
consider the epidemic character ; and that in fever danger arises from 
debility — often an early effect of the poison ; or, on the other hand, 
from the varied and inconstant forms of the secondary functional and 
organic conditions. 

To conclude, it would appear that the more fever and its effects are 
studied — whether at the bedside or in the dead body — the less im- 
portance will be attached to anatomical change. It is to the varying 
condition of innervation and of the chemico-vital states of the fluids 
that the great phenomena of Continued Fever are to be referred. 

In relation to the weighty question of prognosis, you will ever re- 



APPENDIS B. 253 

member that the course of a fever will be favourable in direct pro- 
portion to the absence of anomalous circumstances — even though 
individually these may indicate freedom from disease. 



APPENDIX B. 

The following observations have been furnished me by my colleague, 
Dr. A. W. Foot, as bearing upon the subject of the use of the ther- 
mometer in fever in our medical wards. 

The thermometer has been in daily use in the medical wards of the Meath 
Hospital for many years. Its value as a reliable clinical aid in the diagnosis 
and prognosis of acute disease, especially in essential fever, has been estab- 
lished as fully as it has wherever else this instrument has been habitually 
employed. 

During the past three years, 1871, 1872, 1873, 9248 observations on the 
temperature of the sick have been made in the medical wards. The obser- 
vations are made twice daily, at or about 9 A. M , and 9 P. M., by the clinical 
assistants, the practising pupils in charge of the cases, or the physician on 
duty, and are recorded on the clinical charts of temperature published by 
Harvey and Reynolds of Leeds. 

Of the 9248 observations 3696 were upon cases of typhoid and typhus 
fever; the remainder were upon cases of simple continued fever, scarlatina, 
measles, variola (1026 observations), lung diseases, erysipelas, cerebral 
fever, etc. 

Of the 3696 observations on typhoid and typhus fever, 2649 were upon 
typhoid and 1047 on typhus fever. It has to be observed that there has 
been during the three years above mentioned — 1871, 1872, 1873 — much less 
demand than usual for the admission of " fever" patients — in part perhaps 
owing to the intercurrence of the smallpox epidemic. 

The 2649 observations in typhoid fever were made upon 70 cases. The 
highest temperature registered among these was 107.2° Fahr., and the lowest 
temperature 94° Fahr. 

On 27 occasions temperatures of 105° Fahr. or upwards were registered 
in typhoid fever in 15 patients, and of the 15 patients in whom the temperature 
on one or more occasions reached 105° Fahr. or upwards, five died. On 
four of these cases whose illnesses had been marked by high temperature 
post-mortem examinations were made. 

(a) A girl aged 16, temperature on 30th morning 107.2° Fahr., died on 
the 31st evening. Her mean temperature (51 observations) during the 26 
days she was in hospital was 103.1° Fahr. 

The morning temperature, 107.2°, was coincident with severe rigors, pre- 
ceded by violent pain in the abdomen, ushering in peritonitis, not due to 
perforation, but to propagation outwards of the irritation arising from 
numerous ami extensive ulcerations of the intestinal glands. 

(b) A female, aged 24, who died on the afternoon of the 36th day. Her 
average temperature was 102.1° Fahr., but did not, exceed 105.2° Fahr. 
There were 17 patches of ulceration in the last 53 inches of the ileum, pleuro- 
pneumonia of tin' righl side with exudation of plastic lymph ami sero-tibri- 
nous fluid in the right pleural cavity. 



254: LECTURES OX FEVER. 

(c) A female, aged 20, who died on the 36th day, with most extensive 
ulceration of both solitary and agminated follicles of the ileum. Her mean 
temperature (45 observations) during the 28 days she was in hospital was 
102.3°. 

(rf) A lad, aged 16, who died on the 15th evening of his illness after 
repeated intestinal hemorrhages. The mean temperature (14 observations) 
during the seven days he was in hospital was 103.5°. 

(e) A young man, aged 18, who died on the 15th evening. On the 9th 
evening his temperature reached 105.8°. He was of intemperate habits, and 
had albumen in the urine. The mean of 16 observations on his temperature 
during the eight days he was in hospital was 104° Fahr. In this case a 
post-mortem examination was not obtained. 

Cases have proved fatal in which the mean temperature was not very high, 
especially under two circumstances — great protraction of the fever, and the 
collapse consequent upon perforation. Of this latter kind two examples have 
been verified by post-mortem examination. 

(a) A man, aged 40, brought into hospital \n collapse on the 10th day of 
illness, and who lived until the morning of the 16th day. The mean of 12 
observations during the six days he was in hospital was 99.5° Fahr. His 
temperature on admission was 97° Fahr. ; the highest it reached in hospital 
was 100.8° Fahr. 

(b) A man, aged 27, brought to hospital on the 8th day of illness, and 
who died on the 1 lth morning. His mean temperature during the four days, 
or part of four days, he was under observation was 100.2° Fahr.; the lowest 
point he reached was 97.7° Fahr. 

In contrast with the two preceding cases is the case of a boy aged 18, who 
was brought to hospital in a state of collapse from perforation, and who 
only survived his admission 40 hours; the mean of three observations showed 
an average temperature of 103.7° Fahr. 

In these three cases the intestinal perforation was discovered after death, 
and in each case fecal extravasation had taken place. 

The extremely low temperature of 94° Fahr. was observed in a young 
woman, aged 24, upon the 24th morning of her illness. She was under 
observation during the whole course of her illness, as she got typhoid fever 
while under treatment in the medical wards for a different affection. She 
recovered, but had a long fever. Her chart was discontinued on the 46th 
day She had during convalescence several abscesses over the sacro-iliac 
articulation, which were evacuated by aspiration. 

Mistrusting the accuracy of the practising pupils' observation, I repeated 
it myself at 9^ A. M., and found the temperature of the axilla, with every 
precaution to secure accuracy, and with a correct instrument, to be 94°. The 
body felt cold and clammy like that of one taken out of water; cutis anserina 
was most strongly marked ; she had no new abdominal symptom ; the pulse 
was 88, regular, and easily felt at the wrist ; the respiration 26. The col- 
lapse came on early in the morning ; the temperature on the previous evening 
had been 101.6° Fahr., the pulse 101. She was quite conscious and sensible, 
felt cold, but had no pain anywhere ; there was a tendency to vomit. She 
had not been taking any antipyretic medicine. The temperature began to 
rise from noon, and by 9 P. M. had risen 6.2° Fahr. higher than it had been 
in the morning. This sudden collapse was never accounted for. The high- 
est temperature recorded among 70 observations made on her case was 
105.5° on the 12th evening. 

Among 1047 observations made upon 43 cases of typhus the highest tem- 
perature recorded was 106° Fahr. On twelve occasions temperatures of 



APPENDIX B. 255 

105° Fain*, or upwards were observed in the cases of eight patients, four 
males and four females. Of these eight cases in which temperatures of 105° 
Fahr. or upwards were observed, two died: one — that above alluded to — in 
which the temperature reached 106° on the 16th evening, was a man, aged 
34, affected with well-marked sclerosis of the posterior columns of the spinal 
cord (autopsy made) ; the other was a man of bad constitution, and 43 years 
of age, who succumbed on the 14th day. 

Deaths from typhus of course occurred in cases whose temperature did 
not reach 105° Fahr., other lethal conditions being in operation. For ex- 
ample, a boy, aged li, died on the 10th evening of typhus caught during a 
convalescence from scarlatina, which in its turn had followed closely in the 
footsteps of typhoid fever. He had been exposed to infection in a fever 
hospital. He was brought to the Meath Hospital desquamating, but covered 
with a copious typhus eruption ; he had epistaxis, haamaturia, green vomiting, 
and died in convulsions. His temperature did not exceed 104° Fahr., and 
was twice in the six days he was under observation as low as 98° Fahr. 

The employment' of the thermometer has proved of great value in the 
diagnosis and prognosis of a given case, in distinguishing a factitious from 
a genuine convalescence, in estimating the severity of a case, in estimating 
the results of antipyretic treatment, in detecting imposition, as an indicator 
of complications. The students are soon firmly convinced of the great value 
and importance of medical thermometry, and the patients have never ex- 
pressed themselves as in the slightest degree annoyed or fatigued by even 
the frequent use of the instruments. Its employment is general in the 
medical wards, and by no means confined merely to cases of acute disease. 



INDEX. 



ABDOMEN, affections of the, see Abdomi- 
nal symptoms. 
Abdominal symptoms in fever, 56, 62, 135 
seg., 142 seq., 146 seq. 
swelling, 139 
tenderness, 139 
aorta, Increased action of, 139 
abscess, 149 
Abernethy's chylo-poietic theory of disease, 

219 
Aborted typhus, 91 
Abscess, hepatic, 111, 157 

internal, in yellow fever of 1826-27, 

111, 149 
splenic (?), 149 

simulated by the oedema in phlegma- 
sia, 251 
Absence of anatomical change in fever, 20 

of symptoms unfavourable, 207 
Abuses of the antiphlogistic treatment, 9 
Acetate of lead and opium, 229 
Acland, Dr., on preventive medicine, 35 
on therapeutical research, 188 
Affections, secondary, see Secondary affec- 
tions. 
Affusion, cold, 238 
Age determining propriety of stimulation 

in fever, 197 
Ague, see Intermittent fever. 
Alison on change of type in disease, 12 

on coexistence of various species of 
fever, 52 
Alteratives, danger of using, 228 
Anaemic condition of organs in fever, 58 

murmurs, 131, 132, 133 
Analogy between fevers and toxic diseases, 
24 seq. 
and tubercle and syphilis, 32 
and increased arterial pulsa- 
tions in various diseases, 
140 
from effects of local depletion, 1G3, 
164, -l-l* 
Anatomical character, diseases with an, 22 
chiinge may be absent in fever, 20, 69 

seq. 
expression for fever, wanting, 50 
local symptoms in Fever, 68 
Anatomical school, 182; errors of, 182, 

183 
Anatomy fails to solve the problem of 

healthy life, 19 
Andral's description of French fevers, 67 

17 



Annesley, Mr., on adhesive peritonitis, 157 
Anster's, Dr., translation of Goethe's Faust, 

quoted, 19 
Anticipative stimulation in fever, 195, 215; 
rules for, 195 
in bronchial affection, 223 
Antiphlogistic treatment not always called 
for in primary inflammation, 5 
abuses of the, 9 

contra-indicated in perforative pe- 
ritonitis, 234 
Aorta, increased action of abdominal, 139 

pulse in patency of the, 140 
Aphouia in laryngo-typhus, 106 
Appendix A, 40: Appendix B, 253 
Arachnitis, cerebro-spinal, 165 seq., 239 
Armstrong's theory of fever, 218 
Arteriotomy in delirium, 240 

in headache, 238 
Asthenic pneumonia, 93 
Astringents, 231 

BANKS, Dr., on cerebro-spinal fever, 169 
Bark, failure of, in intermittent fever, 
6, 113 
Beatty, Dr., on frottement of peritonitis, 

158 
Beaumont's, Dr., experiments on digestion, 

190 
Bed-sores, 209; treatment of, 212, 213 

subject to law of periodicity, 210 
Belly, see Abdomen and Abdominal. 
Black vomit, 147 
Blane, Sir Gilbert, on mortality in the 

Peninsular War, 3 
Blisters, 225, 226 

Blood, characters of the, in phlegmasia do- 
lens, 247 
Blood-letting, local, 164, 226, 327, 237 
Blood-waste in fever, 120; urohsematin as 

a sign of, 120 
Boston, North, New York, outbreak of en- 
teric fever at. 46 
Brain, Louis' researches on the, in fever, 
CO seg., 161 
inflammation of the, see Cerebritis. 
Brennan's, Dr., receipt to make a fever, 
220 
couplet on turpentine, 225 
Hrinkley. Bishop, problems on contagion, 

80 
Bromide of potassium, I7"> 
Bronchial affection of fever, 68, 72 at q. 



258 



INDEX. 



Bronchial affection of fever described, 73 
not primarily bronchitis. 75 
subject to law of periodicity, 

77 
treatment of the, 77. 223 seq. 
simulating phthisis, 78, 79 
associated with weak heart, 
223 
muscular fibre, paralysis of, 105, 223 
Bronchitis, see Bronchial affection. 
Broussais, theory of fever held by, 6, 218 
error of his school, 21 seq., 102, 137, 
141, 161, 181, 218, 228 
Buffed and cupped blood-clot, 16 

nALCULI, bronchial, 83 

\J Camp fever, 45 

Cancerous cachexia, phlegmasia dolens in, 

246 
Cardiac muscular fibre, weakening of, 105 
affections in fever, 106 seq. 
softening, 1 17 
excitement, 119, 200 
depression, 121, 200 
murmurs, 131. See Heart. 
Catheterism in retention of urine, 243 
Cause of fever, proximate, undiscovered, 

23 
Causes of fever, various, 32, 34, 48, 185 
Cerebritis in fever, 162, 222 
Cerebro-spinal complications, 159 seq., 165 
seq., 173 seq. 
causes of, 164 
fever, 103, 160, 165 seq. ; symptoms, 
170 
an essential disease, 168 
Change of practice in treatment of fever, 10 
of type in disease, 10 

Alison's views on, 12 seq. 
Christison's views on, 12 seq. 
the author's views on, 14 seq 
evidence from symptoms, 14 
seq. 
from appearance of 

drawn blood, 16 
from pathological ap- 
pearances, 16 
from isolated sthenic 

cases, 17 
from influence of treat- 
ment, 18 
Change, anatomical, see Anatomical change. 
Changes, local, in fever, nature of the, 64 

seq. 
Characteristics of fever, 54 
Chest, effusion into the, 77, 105 
Cheyne, Dr., on hysteria in fever, 177 

on intestinal ulceration in late 
stage of fever, 63, 79 
Chloral in fever, 175. 243 
Choice of food in fever, 189 
Cholera, first invasion of, coincident with 
occurrence of change of type in disease, 
18 
Christison, Sir Robert, on change of type 
in disease, 12 



Classification of diseases, 22 seq. 
Clutterbuck's theory of fever, 218 
Cold lotions, 237 
affusion, 238 
Colles, Mr. Abraham, on simulative ague, 

113 
Collins, Dr. E., on epidemic of 1867, 166, 

seq., 239 
Complications, see Secondary affections. 
Congestions of the lung in fever, 89 
Consolidation of lung, treatment of, 226 
Consolidations of the lung in fever, 89 ; 
critical, 91 
ending in sphacelus, 96 
differential diagnosis of, 97 
Constipation, treatment of, 229 
Contagion, 23, 27 seq. 

implies essentiality in disease, 28 
arguments in favour of, 29 seq. 
problems on, 30, 31 
in enteric fever, 46 
Continued fever, see Fever. 
Continuity, diagnosis of internal solutions 

of, 154 
Convalescence, imperfect, 79 
Convertibility of zymotic diseases, 39 
Convulsions, 243 ; urremic, 244 
Correlation of zymotic diseases, 39 
Corrigan, Sir Dominic, cases of cerebritis 
in fever, 163 
on attention to the bladder, 243 
Crepitus redux absent in resolution of ty- 
phous consolidation, 102 
Crisis in fever, 92 

Critical consolidation of lung, 91, 226 
Croly, Mr., on cerebro-spinal fever, 171 
Curative contrasted with preventive medi- 
cine, 34 seq. 
Cusack, Mr., cases of tubercular fever, 

88 
Cusack, Dr. Samuel, on wine and opium in 
puerperal fever, 235 

DANGER, sources of, to patient, 21, 188, 
137 
Deglutition, power of, retained, 205, 214 
Delirium, Louis' investigations on, liO seq., 
103, 159, 161 
in fever 239; treatment of, 240 seq. 
toxic, 240 

asthenic, 241 ; stimulants in, 241 
Depletion, local, 163, 226, 227, 237 
Deposit, specific typhous, 64 seq. 
Description of continued fever, 20, 217 
Diagnosis iu presence of fever, 56, 59, 98 
from want of accordance of phenomena, 

82, 134 
of softening of the heart in fever, 134 
of intestinal perforation, 140 
of internal solutions of continuity, 154 
Diarrhoea, treatment of, 229; diet in, 231 
Digestion, Dr. Beaumont's experiments on, 
190 
in fever, 191, 192; influence of rank 
on, 192 
Disease, theories of, 5, 6 



INDEX. 



259 



Disease, return to sthenic forms of, 17 
vital character of, 18 
sources of danger in, twofold, 21, 188, 

classification of, 22 seq. 
toxic, 25 

endemic, see Endemic disease, 
essential, 29; contagious, 33 

acute, two phases in history of, 

33 
correlation of zymotic, 39 
convertibility of zymotic, 39 
Dothinenteritis. 136, 137 
Dry-cupping, 225, 244 
Dublin, epidemics in, 37, 42, 44, 165, 172 

}?CCm r MOSES, 168 
\i Eclectic school, 183, 217 
Edinburgh, epidemics of fever in, 13 
Effusion into the chest, 77, 105 
Embolism, pulmonary, in phlegmasia dolens, 

248 
Emetics in bronchial affections, 224 
Empiric, 180 
Empiricism, 180 
Endemic disease arises independently of 

contagion, 28 
Enemata, nutrient, 214 
aperient, 229 
of turpentine, 230, 245 
Enteric fever, 45; contagious, 46 
and typhus contrasted, 45 
causes of, 38; Murchinson on, 
38; Sir W. Jenner on, 38; au- 
thor's views, 38, 39 
resemblances between, and typhus, 

50.se?., 135, 208 
and typhus, species, not genera, of 
fever, 51, 135 
Epidemic character, 42, 44, 252 
Epidemic of 1826-27, 44, 137, 143, 146 
of 1847, 52 

of 1867, 160, 165, seq. 
of 1S46, 172 
Epidemics of fever in Edinburgh, 13 

in Dublin, 37, 42, 44, 165, 172 
in Stockholm, 130 
Epidemics within epidemics, 166 
Eruption of rose-spots, 145 
Eruptions, 145, 208 
Essentinl disease, see Disease. 

fever, 55 
Essentialism in fever proved, 44 
f'jui poisseux of heart, 107 
Excitement of heart in fever, 110 
Expectoration of calculi after fever, 83 
Eye, condition of the, in fever, 61 

FAMTNE fever, 52 teg. 
Fatty degeneration of heart, slow pulse 
in, 129 
Fear, physical, 3 
Febris nigra, 166, 173 

Fever, continued, importance of a practical 
knowledge of, 1 



Fever, principle of treatment of, the same 
in all its forms, 2, 179 seq 
mortality of, in the Peninsular War, 3 
may be the opposite of an inflamma- 
tion, 5 
described, but not defined, 20, 217 
proximate cause of, as yet undis- 
covered, 23, 184 
nature of its secondary affections, 26 

seq 
causes of, are various, 32, 34 seq., 48 
contagion a cause of. 27 seq. 
analogy between, and tubercle and 

syphilis, 33 
varieties of, dependent on epidemic 
character, 42 
observed in the same epidemic, 
43, and in members of the same 
family, 43 
resemblances between forms of, 49, 

50 seq. 
species, not genera, 51, 135 
characteristics of, 54 
no anatomical expression for, 56 
pathological conditions of, 66 seq. 
treatment of, change of practice in, 10, 

121 
bronchial affection of, 72 seq. 
pulmonary affections of. 72 seq. 
cardiac affections of, 106 seq. ; intes- 
tinal, 235 seq. 
cannot be cut short, 186 
intermittent, see Intermittent fever, 
temperatures in [Appendix BJ, 253 
Fever-odour, 197 

Fevers, distinctions between, and neuroses, 
23 
analogies between, and toxic diseases, 

24 seq. 
subject to law of periodicity, 23 
causing secondary affections, 23 
transmissible by contagion, 23 
knowledge of, negative, 122 
Flint, Dr. Austin, on contagiousness of 

enteric fever, 46 
Floccitatio, 243 

Foetal heart in fever, 124, 128, 199, 203 
Food in fever, 188 

Dr. Graves on giving, 188 seq. 
choice of, 189; rules for giving, 
190 
Foot, Dr. A. W., a case of hysteria in fever, 
174 
observations on temperature in 
fever [Appendix 15], 253 
Fordyce, Dr., definition of fever, 179 
/''itiiilrni/iiiilr, Mrnini/ilr. 1 * • T 

Frottement of peritonitis, 158 
Functional or nervous local symptoms in 
fever, 57, 59, 159, 165, 173 

GANGRENE of bin-. 96, 227 
in epidemic of 1826-27, 147 

(iiingreiious vesicles. 2<I9 

Qastro-cntnrrhal typhus, 7:; 

Genera of fever do not exist, 51, 135 



260 



INDEX. 



Geographical variation in form of fever, 67, 

206 
Goethe, Quotation from, 19; referred to, 

184 
Gordon, Dr., on cerehro-spinal fever, 166, 
1G8, 171 
and coincident epidemic of 
measles, 173 
Graves, Dr., on causes of epidemics of fever, 
36 
of typhus, 37 
on temporary pneumothorax in 

pneumonia. 101 
on yellow fever of 1826-27, 111, 

150, 172 
on treatment of fever, 182; on 

food in fever, 188 
on nutrient enemata, 214 
on value of turpentine, 225 
on acetate of lead and opium, 229 
on opium in intestinal perforation 

and peritonitis, 233 
opposed to treatment of perfora- 
tive peritonitis by antiphlogis- 
tics, 234 
on tartar emetic and opium, 242 
Grimshaw. Dr., on defective sanitary state 

of Dublin, 38 
Gurgling in ileo-ctecal region, 141 

HEMORRHAGE, intestinal, 235; treat- 
ment of, 236 
Hemorrhagic smallpox, 173 
Hardcastle, case of, 206 seq. 
Harley, Dr. George, on urobtematin as an 

indication of blood-waste, 120 
Harvey's, Dr., advice, 191 
Haverty, Mr., on cerebro-spinal fever, 169 
Hayden, Dr., observation of tympanitic re- 
sonance of lung, 101 
Head symptoms in fever, 56, 59 seq., 159 
seq. 
treatment of, 237 seq. 
absence of, an indication for use 
of stimulants, 215 
retraction of, 171 
shaving the, 238 
Head-ache, 237 ; treatment of, 237 
Heart, fatty degeneration of, slow pulse in. 
129 
chronic failure of the, 196 
escape of, in fever, 200 
arrest of the, in phlegmasia dolens, 248 
in fever, 61, 106 seq., 114 seq., 121 
seq., 127 seq., 198 seq. 
not altered except in rate, 115, 

118 
weakened after a few days, 116, 

199 
excited, 117, 119, 200 
softening of, 117 
depression of, 121, 200; more 

marked in typhus, 122 
diminution of impulse of, 122 seq., 

199 
vermicular impulse of, 123 



Heart in fever, diminution of sounds of, 
125 seq., 199 
physical signs of, 126, 199 
murmurs of the, 131 seq. 
" Heart, foetal," 124, 128, 199, 203 
Hepatic abscess, 111, 157 
Hudson, Dr., on tympanitic resonance in 
typhous consolidation of luug, 
99 
cerebri tis in fever, 162, 163 
arteriotomy in delirium, 240 
on turpentine in tympanites and 
sleeplessness, 242 
Humoral theory of disease, 5 
Huss, Professor, on epidemic of 1841 at 
Stockholm, 130 
on value of turpentine, 225 
Hypercatharsis, danger of, 229 
Hysteria in fever, 173 seq. ; Dr. Foot's case 
of, 174 
significance of. 173, 176 
masking diseases, 176 
outbreak of, in fever-ward, 177 

ICE, 238; mode of applying, 238, 240 
Idiopathic inflammation, 184 
pyremia, 110; iritis, 184 
Ileo-Cfecal tenderness, 139 

gurgling, 141 
Ileum, ulceration of, 143; latent, 139 

perforation of, 153 
Impulse of heart, progressive diminution 
of, 122, 123, 124, 199 
" vermicular," 123 
effect of position on, 124 
Indications for stimulation, 197 
Inflammation, erroneous views as to the 
universality of, 4 
acute febrile diseases may be the oppo- 
site of, 5 
primary and antiphlogistic treatment 

of. 5 
erroneous ideas conveyed by the word, 

8 
secondary, in fever, 103, 142, 224 
something the reverse of, 4, 130 
of brain rare in fever, 159 
a cause of nervous symptoms, 164 
"Inflammation, healthy," 110 
Inflammatory theory of disease, 5, 181 

symptoms in fever, 58 
Insomnia, 242 
Intermittent fever, 112 

failure of bark in, 6, 113 ; Mr. Colles 

on, 113 
mode of origin of, 28 

symptomatic of urinary disease, 
113 
Intestines, ulceration of the, indicated by 
quick pulse, 108 
perforation of the, 151 seq. 
Intestinal affections, secondary, 135 seq., 
142 seq.. 146 seq , 227 seq. 
treatment of, 227 seq 
perforation, 151 seq.; latent, 151 
intussusceptions, 148 



INDEX. 



261 



Intestinal hemorrhage, 235 
Intussusceptions in yellow fever of 1826-27. 

148 
Involuntary muscular tissue in fever, 117 
Iritis, specific and idiopathic, 184 

JAIL-FEVER, 45 
Jaundice in fever of 1826-27, 147 
Jenner, Sir William, causes of enteric fever. 
39 



K 



ENNEDY, Dr. Heury, on coexistence of 
various species of fever, 52 
on cerebro-spinal fever, 169 



LAENNEC on waste of red blood in fever, 
120 
on phenomena of pneumonia, 95 
on softening of the heart, " Vital pois- 

seuz," 107, 114 
on muscular softening, 118 
on error as to quick pulse in conva- 
lescence, 108, 245 
Laryngeal muscles, paralysis of, 105 
Laryngo-typhus of Rokitansky, 104 seq. ; 

aphonia in, 106 
Larynx, inflammation of, 177 
Latency of secondary affections, 74, 138 

of intestinal perforation, 151 
Law of periodicity, 1, 6, 21, 64, 77, 141, 
187, 188, 210 
interfered with by local irritation, 

7, 141, 238 
action restored, 238 
Law, Dr. Robert, case of softening of spleen, 
150 
on tartar emetic and opium, 242 
Lawrence, Dr., on yellow fever, 148 
Leeching, see blood-letting, or depletion. 
Levy on cerebro-spinal fever, 167 
Liver, see Hepatic. 

Local changes in fever are symptomatic, 
64 
are subject to periodicity, 64 
symptoms in fever, 57 

functional or nervous, 57 
anatomical, 57 

secondarily inflammatory, 57 
due to anaemic condition of organs, 
58 
change masked by neighbouring irrita- 
tion, 153 
Lombard's, Dr., views on British fevers, 08 
Louis, numerical system of, 29 

investigations on delirium, 60 seq,, 
mi:;, i.v.i, 162 
on softening of the heart, 114, 
117, 122 
Lyons, Dr., on tympanitic resonance of 
lung, 100 
on cerebro-spinal fever, 16!) 

MacDOWEL, Dr. B., affection of the joints, 
108 
Mackintosh, Dr., on emetics in bronchial 
affection, 221 



MacSwiney, Dr., on cerebro-spinal fever, 

169 
Malaise in enteric fever, 138 
Malignant fever, 45 

purpuric fever, 166 
smallpox, 173; measles, 173 
Mayne, Dr., on cerebro-spinal fever of 1 846, 

172 
Measles, malignant, 173 
Medicine and surgery, hurtful effects of 
separation of, 7 
preventive, contrasted with curative, 
34 seq. 
Membranes, mucous, in fever, 66 

serous, in fever, 66 
Meningite foudroyante, 167 
Meningitis, epidemic cerebro-spinal, 166 
Mental study, unfavourable effect of, 71, 

215 
Mistura olei et opii, 230 
" Mixed" or " semi-involuntary" muscular 

fibre in fever, 118 
Mucous membranes in fever, 66 
Murchison, Dr., on causes of enteric fever, 
38 
on distinctions of fevers, 52 
on rarity of cerebritis in fever, 

160 
on tentative stimulation, 216 
on case of latent peritonitis, 232 
on treatment of peritonitis, 235 
Murmurs, cardiac, in fever, 131 seq. 

more frequent in enteric than in 
typhus, 131 
Muscular softening in fever, 105 seq., 117 
seq 
rigidity of abdomen, 141 

NERVOUS local symptoms in fever, 58, 
159, seq. 
causes of, 222 
Neuroses, 22 

distinctions between, and fevers, 23 
Nourishment, 188; see "Food." 
Numerical system of Louis, 29 

fallacies of, 216 
Nurse-tending, skilled, 214 
Nutrient enemata, 214 
Nymphomania, 174, 175 

a?DEMA in phlegmasia, simulating ab- 
L scess, 245 
Opisthotonos, 172 
Opium, 229, '233 seq., 212 

in intestinal perforation, 233 
mode of action of, 233 
tolerance of, 234 
wine and, in puerperal fever, 234 

PAGET, Dr., on problems to establish ex- 
istence of contagion, 81 
Paralysis of laryngeal muscles, 106 
of bronchial muscles, 105, 223 

of cardiac muscles, 106 
Parenchymatous structures in fever, 66, 94 
Parr, Mr., on turpentine-punch, 225 



262 



INDEX. 



Patency, aortic, " steel-hammer" pulse in, 

140 
Pathognomonic physical signs do not exist, 

134 
Pathological conditions in fever, 6G seq. 

of heart in fever, 127 
Pathological school, 182 
Perforation with peritouitis simulating 

poisoning, 219 
Periodicity, law of, 6, 21, G4, 77, 141, 187, 

188, 210 
Peristaltic action in perforative peritonitis, 

Peritoneum, insusceptibility of, to adhesion. 

157, 231 
Peritonitis, 151 seq ; limited, 102 
treatment of, 231 
from eruption of pus, 155, 156 
from perforation, 170 
Phlebitis, question of, 246 
Phlegmasia dolens, indicated by quick pulse 
in convalescence, 100, 245 seq. 
treatment of, 251 
symmetry of affected limb in, 245 
etiology of. 246 
cases of. 112, 248 
Phthisis, rarity of intestinal perforation in, 
151 
simulated by bronchial affection, 78, 79 
a sequela of fever, 80 
Physical signs, no pathognomonic, 134 

of heart in fever, 126. 199; a 
guide in stimulation, 201 
fear. 3 
Physiological theory of disease, 5 

difference between pus and white-blood 
cell, 157 
Physiological school, 182 
Physiology, experimental, fallacies attend- 
ing, 187 
Pin-hole pupil, 242 
Pneumonia, typhoid. 89 

croupous, or plastic, 247 
Pneumonic complication of fever, 89, seq. 
forms. 89, 22*; 
treatment, 226 
rneumo-thorax. 232 
Pneumo-typhus, 72 
Points of resemblance between forms of 

continued fever, 49 
Poison of fever, a cause of nervous symp- 
toms, 164 
Poisoning simulated by internal perfora- 
tion, 219 
Post-mortem appearances in yellow fever of 

1826-27, 147 
Poulticing, 225, 227 



Practice, change of, in treatment of fever, 

10 
Pratt's, Dr., views on the causation of 

fever, 41 
Preventive medicine, 34 seq. ; object and 
scope of, 35 
Dr Acland on, 35 
Principle of treatment of continued fever, 
179 seq. ; the same in all its forms, 2 



Prognosis, 252 ; influence of appearance of 
vesicles on, 211 
in cardiac affection of fever, 130, 145 
in cerebro-spinal fever, 159, 222 
Proximate cause of fever undiscovered, 23 
Puerperal women liable to simulative ague, 
113 
fever, wine and opium in, 235 
phlegmasia dolens in, 246 
Pulmonary affections of fever, 70, 72 seq., 
222 
treatment, 226 
embolism in phlegmasia dolens, 248 
Pulse not always a guide in fever, 106, 198 
full and bounding, coincideutly with 

weak heart, 107, 198 
slow in convalescence, 107, 129, 204; 

in fatty degeneration, 129 
rapid in convalescence, 108 
weak with excited heart, 119 
" steel-hammer," 140 
lessened rate of, sign of agreement of 
stimulants, 203 
Pulsation, increased arterial, 139 
Purpuric fever, 166; smallpox, 173 
Pus, escape of, into peritoneum, 155, 156 

vital characters of, 157 
Putrefaction, early, in cerebrospinal fever, 

171 
Putrid fever, 45 

Pyaemia idiopathic, 110; secondary, 142 
Pythogeuic fever, 39, 45 

fc*/"\UACK" and " empiric" contrasted, 180 
lc£ Quick pulse in convalescence, 108, 245 
its significance, 108 
with tuberculosis, 108 
in secondary intestinal inflamma- 
tion. 108 
in phlegmasia dolens, 109 

RACE, influence of, 67, 206 
Rank, influence of, on symptoms. 71, 
197; on choice of food, 192; on giving 
of stimulants, 215 
"Rational school." 182 
Reactive local inflammation, 142, 164, 224 
" Receipt to make a fever," 220 
Receptivity of disease, 26 
Relapsing fever, 52 seq. 
of 1847-48, 53 
Resemblances between forms of continued 
fever, 49 
typhus and enteric fevers, 50 seq. 
Resonance, tympanitic, in typhous consoli- 
dation of lung, 99 seq. 
Retention of urine, 178, 243 
Retraction of head, 171 
Piheumatism, local increased arterial action 
in, 140 
no specific treatment in, 2, 187 
Rigidity of abdominal muscles, 140 

of neck in cerebro-spinal fever, 171 
Rokitansky on reactive inflammation, 05 
on broncho-typhus, 69 



INDEX. 



263 



Rokitansky on pneumo-typhu3, 72 

on laryngo-typhus, 104 seq. 
Rose-spots, 145 

Routine systems of practice, 218 
Routinism to be deprecated, 216 
Rules for giving food in fever, 190 

stimulants in fever, 196, 351 
Rutty, Dr., observation on treatment, 45 

SANITARY science, 34 seq 
Secondary affections of essential dis- 
eases, 20, 21, 56 
of continued fever, 26, 67 seq. 
treatment of, 222 seq. 
nature of the, 56 
geographical variation of, 67 
seat of, influenced by locality, 70 

by social rank, 71 
alternating. 78 
bronchial affection, 72 seq. • treatment 

of, 223 seq. 
pneumonic affection, 89 seq. ; treat- 
ment of, 225 seq. 
its three forms, 95, 96 
cardiac affection, 106 seq. ; treatment 

of, 192 seq. 
intestinal affection, 135 seq. ; treat- 
ment of, 227 seq. 
cerebral and nervous affections, 159 
seq. ; treatment of, 63 
Sedatives, 242, 243 

Sequela of fever, tubercule a, 80, 108 seq. 
Serous membranes in fever, 66 
Shaving the head, 238 
Sibson, Dr., on treatment of rheumatic 

fever, 1 
Signs, physical, of heart in fever, 126, 199. 

201 
Sim u In lire ague, 113 
Sleeplessness, 242 

treatment of, 242 
Slow pulse in convalescence, 107, 129 

in fatty degeneration of heart, 
129 
Smallpox, epidemic of hemorrhagic, 173 

local depletion in, 164 
Smith, David, on coexistence of various 

species of fever, 52 
Smith, Professor R. W , case of enlarge- 
ment of lung in croupous pneumonia, 
247 
Social rank, influence of, on symptoms of 
fever, 71, 197 
on choice of food, 192 
Softening of the heart in fever, 107, 114 
begins in left ventricle, 
11--,. 122 
Bolidist theory of disense, 5 
Sound of heart, diminution of first, 124, 
199 
extinction of first, 125, 199 
relative augmentation of second, 
125 
Sounds of heart, diminution of both, 125, 
199 



Sounds of heart in fevers, phenomena at- 
tending the, 124 seq. 
Spasms, 90 

Species, not genera, of fever, 51, 135 
Specific typhous deposit, 64 seq. 

treatment in disease not attainable, 2, 
185 
Sphacelus of lung, 96 ; illustrative cases, 

97, 227 
Spleen, enlargement of, in 1826-27, 148 ; 

softening of, 150 
Splenic abscess, 149 
Sponging of skin, 245 
Spotted fever, 45, 166 
"Steel-hammer" pulse, 140 
Sthenic forms of disease, return to, 17 
Stille" on nature of cerebro-spinal fever, 

168 
Stimulants in fever, 116, 130, 188, 193 seq., 
201 seq., 212 seq. 
question of nutrient properties of, 194 
disagreement of, 195,215 
a?iticipatwe use of, 195, 223 

dependent on age and habits, 
196, 215 
heart, 199 seq 
signs of agreement of, 202, 215 
necessity for persevering in use of, 

214 
should not be given by routine, 217 
in delirium, 241 
Stockholm, epidemic of 1841 at, 130 
Stokes, Dr. Whitley, his anecdote of Mr. 
West at Rosetta, 8 
researches on contagion, 30, 33, 
38 
Subsultus tendinum, 243 
Suppression of urine, 244 
Surgery, exclusive study of, to be depre- 
cated, 2 
Surgical student advised to study fever, 1 
Swelling, abdominal, in fever, 139 

treatment of, 229 
Symptoms, latent, 73, 138, 139, 151, 152 
of cerebro-spinal fever, 170 
absence of, an unfavourable feature, 
207 
Symptomatic fever, 55, 141 
Symptomological school, 6, 181 

theory of disease held by, 6, 181 
Syncope, death by, in phlegmasia dolens, 

248 
Syphilis, analogy between, and fever, 33 
System, numerical, of Louis, 29 

TARTAR emetic, dangers of, 224 
and opium, 242 
Temperature increased, constant in fever, 

165 
Temperatures in fever [Appendix B], 253 
Temporal artery, opening of, 288, 240 
Tenderness of abdomen, 189 
Theories of disease. 5, 6, 218 
Therapeutical research. 187 
Therm ometrical observations in fever. 258 
Thirst, 189 



264 



INDEX. 



Thoracic symptoms in fever, -56, 62, 72 

seq., 89 seq. 
Timidity from want of bedside experience 

of fever, 3 
Todd, Dr., on secondary pyaemia, 142 

on stimulants in fever, 194 
Tongue, the. in fever, 141 
Tonics in fever, 130 
Toxic diseases, 24 
Transfusion of blood, 120 
Treatment of fever based on general prin- 
ciples, 2, 131, 179 seq. 
antiphlogistic, not exclusively to be 

used in primary inflammation, 5 
of typhus and enteric fever, essen- 
tially the same, 48 
objects to be sought for in, 48 
of smallpox by local depletion, 164 
no specific treatment, 186 
of the local secondary affections, 222 

seq. 
of bronchial affection, 77. 223 seq. 
of intestinal affection, 227 seq. 
of head affection, 237 seq. 
phlegmasia alba dolens, 251 
fever, change of practice in, 10 

by food and stimulants, 188 seq. 
Treatment, <niticipative, 195 
Trousseau, Professor, on phlegmasia alba 

dolens, 246 seq. 
Tubercle, analogy between, and fever, 33 
as a sequela of fever, 80, 108 
acute coexisting, 80 
acute consequent, 81 
consequent softened, 81 
indicated by quick pulse in convales- 
cence, 108 
Tubercular cachexia, phlegmasia dolens in, 

246 
Tubercular fever, 84 seq., 152; contagious, 

88; an essential disease. 88 
Tumefaction of belly, 139 
Turpentine fomentations, 225 

injections, 229, 230 
"Turpentine-punch," 225 
Tussis clangosa, 104 
ferina, 174, 176 
Tympanites, 139, 146, 230; treatment of, 

229 
Tympanitic resonance in typhous consolida- 
tion of lung, 99 
Dr. Hudson'- view, 99 
Dr. Lyons' view, 100 
Dr. Hayden's view, 101 
author's view, 101 
Type in disease, change of, 10; see Change 
of type. 
Alison on, 12 
Christison on, 12 seq. 
the author on, 14 secq. 
Typhoid fever, see Enteric fever. 
Typhoid pneumonia, 89 ; its forms, 90 
not dependent on gastritis, 98 
Typhous deposit, specific, 64 seq. 
vital character of, 65 



Typhus, 45 : causes of, Dr. Graves on, 37 
and enteric contrasted, 45 seq. 

resemblances between, bUscq., 136, 

208 
species, not genera, of fever, 51, 
135 
aborted, 91 
laryngo-, 104 seq. 
broncho-, 68; pneumo-, 72 
Typhus abdominalis, 72 
gravior, 45 
malignant, 45 

ULCERATION of the intestines indicated 
by quick pulse, 108 
latent, 139 

in epidemic of 1826-27, 143 seq. 
Uraemia, 244 

a cause of nervous symptoms, 164, 243 
Urtemic convulsions, 244 
Urine, retention of, 178, 243 

effervescence of, in uraemia, 244 
suppression of, 244; its treatment, 244 
Urohrematin as an indication of blood- waste, 
120, 121 

VARIETIES of continued fever, 42; see 
Fever, continued. 
Veins, cordy and painful state of, 246 
Venesection in fever, 10, 15 
Venienti occurrite morbo, 195 
Venous irritation, 246 
"Vermicular" impulse of heart, 123 
Vesicles in fever, 209 

influence on prognosis, 211 
Vis medicatrix naturae, 218 
Vital phenomena, study of, the basis of the 
healing art, 18 
character of disease, 19, 184 

typhous deposit, 65 
depression of the heart, 204 
Voluntary muscular tissue in fever, 117, 

118 
Vomiting, black, 147 

WANT of accordance of phenomena, di- 
agnosis from, 82, 134 
Warm stupes in headache, 237 
Weakness of the heart, 116, 199 
West, Mr., and his party, at the Rosetta 

Pest Hospital, o 
White blood cells and pus corpuscles, 157 
Whitlow, increased arterial pulsation in, 

139 
Wine in fever, 213 ; see Stimulants, 
and opium in puerperal fever, 234 
sedative effect of, 242 
Wolff. Mr. A., on the correlation of diseases 
(foot-note), 39 

" yELLOW fever" of 1826-27, 111, 137, 

I 146 seq.. 166 
Yellow fever, Dr. Lawrence on, 148 

ZYMOTIC diseases, convertibility of, 40 
correlation of, 40 



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